Jefferson's Cancer Survivorship Program will help you understand what it means to be a cancer survivor and what to expect from your cancer diagnosis, treatment and follow-up care. This Program is for current patients, cancer survivors and loved ones who have lived with a cancer diagnosis or have undergone cancer treatment at Jefferson.

1. Cancer Survivorship and Integrative
Cancer Care
Daniel A. Monti, M.D.
Professor and Director
Myrna Brind Center of Integrative Medicine
Thomas Jefferson University and Hospital

2. Jefferson-Myrna Brind Center of Integrative Medicine: 925 Chestnut St.
STE 120

3. Our Survivorship Model
• You and your primary KCC specialists (medical, radiation
and surgical oncology) are at the helm
• Focus on Proactive Lifestyle Management (diet, activity
level and stress management) to support and enhance
care plan
• Phenotype = Genotype + Life

4. The Goals of Integrative Cancer
Survivorship Care
Reduction of Risk
Symptom Management
Quality of Life
Decrease Stress
Test Adjunctive therapies

5. Trend Modification:
• Lifestyle
• Environment
• Nutrition
*Will account for up to 75% of health and
life expectancy after 40
Murray and Lopez (1997)

6. Highest male healthy life expectancy
Lancet, 2012
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•
•
•
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•
•
•
Rank (95% uncertainty intervals)
Japan 1 (1–2)
Singapore 2 (1–6)
Switzerland 3 (2–10)
Spain 4 (2–8)
Italy 5 (3–14)
Australia 6 (4–15)
Canada 7 (4–18)
Andorra 8 (2–28)
Israel 9 (3–18)
South Korea 10 (4–18)

7. Highest female healthy life expectancy
Lancet, 2012
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•
•
•
•
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•
•
•
•
Rank (95% uncertainty intervals)
Japan 1 (1–1)
South Korea 2 (2–7)
Spain 3 (2–6)
Singapore 4 (2–17)
Taiwan 5 (2–16)
Switzerland 6 (2–22)
Andorra 7 (2–33)
Italy 8 (5–18)
Australia 9 (6–19)
France 10 (7–26)

8. Nutrition is a key element of
Integrative Oncology
-Food is an important factor in
gene expression.
-Food is emphasized over
supplements.
-Food affects cancer risk.
-Food affects cancer outcomes.

9. Let your food be your medicine
And your medicine be your food
Hippocrates

10. Body Fat Increases CA Risk
• Body fat secretes cytokines that promote
inflammation
• Too much body fit triggers insulin
resistance, raising levels of insulin and
growth factors that promote cancer
• Fat increases estrogen production
• Increase in body fat may impair immunity

12. Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2000
1990
2010
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%

13. Obesity Rates (OECD, 2012)
35%
30%
Rate of obesity
25%
20%
Hungary
Ireland
England
15%
Canada
USA
10%
Spain
Italy
France
5%
Switzerland
Korea
0%
1970
1975
1980
1985
1990
Year
1995
2000
2005
2010

14. Insulin and IGF-1 and Cancer
Gallagher and LeRoith, Trends in Endo and Metab, 2010

15. Obesity-Associated Malignancies
• Breast (postmenopausal)
• Endometrium
• Prostate
• Kidney
• Colon
• Esophagus
• Pancreas
• Gallbladder
AICR report
estimates
that obesity-related
excesses
of these 7 cancers
account for approx
105,000
preventable deaths
a year in the US

16. WCRF/AICR Dietary Recommendations to
Reduce Cancer Risk 2007
• Limit consumption of red meats (beef, pork and
lamb) and avoid processed meats

17. Nutritional Risk Reduction Strategies
Eat More:
•
Phytoestrogens
– Soy foods
•
•
•
•
•
•
– Flaxseed
Cruciferous vegetables
Garlic and onions
Turmeric and ginger
Green tea
Omega 3 fatty acids
Vitamin D

18. Estrogen Adducts,Cancer,
Dietary Effects
*Compelling evidence supports the hypothesis that specific
estrogen metabolites, predominantly catechol estrogen-3,4
quinones, react with DNA to form depurinating estrogen-DNA
adducts (review: Pruthi et al, 2012)
*I3C and DIM (found in cruciferous veggies) are potent inducers
of steroid-metabolizing enzymes such as 2-hydroxylating
cytochrome (cyp1A1) that converts circulating estradiol, a
mitogenic estrogen, to a 2-hydroxy metabolite that correlates
with lower risk of breast and gynecological cancers and may
enhance chemo in pancreatic cancer (Banerjee et al 2009)

19. Chronic Inflammation
• Mood Disorders
•
•
•
•
•
•
Autoimmune Disorders
Cancer
Cardiovascular Disease
Psoriasis
Alzheimer’s Disease
Type I and II diabetes mellitus

20. Nutrition and Inflammation
Foods that increase
inflammation
Red meat, eggs
Foods that decrease
inflammation
Omega-3 fats
Sugar
Spices and herbs
turmeric,,rosemary,ginger,
Hot peppers
alcohol
Green tea
High-Glycemic Foods
like Soda Pop
Low-Glycemic Foods
like Green Veggies

21. Chronic Inflammation
The Gut is an important variable
• GALT > Nitric Oxide > intestinal permeability > liver
alarm system : Kuppfer Cells > message to whole
body : red alert, man your battle stations!
• Anti-inflammatory Armor: FOOD, pro-biotics/
supplements, Sleep, Stress Reduction

22. Omega-3 fat
• Highly promising for supporting:
– Physical health
– Mental health
– Disease prevention
*Sources of Omega-3 fats include cold water fish, flax
seeds, raw walnuts, and others

23. Metabolic Pathways of Essential Fatty Acids
Omega-6 Fatty Acids
Omega-3 Fatty Acids
(e.g. corn, safflower, sunflower oil)
(e.g. canola, flaxseed oil, fish oils)
Linoleic acid (LA)
Alpha-linoleic acid (LNA)
delta-6-desaturase
delta-6-desaturase
Gamma-linolenic acid (GLA)
Steridonic acid
(e.g. evening primrose, borage,
and black currant seed oils)
Eicosapentaenoic acid
Dihomo-gamma-linolenic acid (DGLA)
delta-5-desaturase
PGE1
(e.g. fish oils)
delta-5-desaturase
Arachidonic acid
cyclooxygenase
PGE2
DHA
EPA
(anti-inflammatory)
lipoxigenase
LTB4
cyclooxygenase
PGE1
(anti-inflammatory)
(e.g. Mg, Zn)
lipoxigenase
LTB5
(anti-inflammatory)
(pro-inflammatory)
(pro-inflammatory)
*Factors thought to impair delta-6-desaturase activity include Mg, Zn, and B1 deficiency; aging,
alcohol, trans fatty acids; and high cholesterol levels.

24. Transformation of food chain
from 1960 to 2000
x20
Omega-6
/Omega-3
x15
x10
x6
Butter
Pork
Beef
Eggs
Ailhaud et al., Prog. Lip. Res., 2006

27. Traditional Dietary approaches such as
Fasting and Dietary Cleanses may have a
scientific basis
“Fasting vs dietary restriction in cellular protection
and cancer treatment: from model organisms to patients”
Lee and Longo: Oncogene (2011) 30, 3305-3316

28. Multivitamins in the Prevention
of Cancer in Men:
The Physicians’ Health Study II
JAMA, 2012
Conclusion: In this large prevention trial of male
physicians, daily multivitamin supplementation
modestly but significantly reduced the risk of total cancer.
- Adds to evidence that low-dose vitamins (versus high
dose) can have a protective effect
- Underscores need to study long-term effects, which also
was seen in the WHI Vit D and calcium study showing
total reduction in cancer (J Bone Miner Research, 2012)

29. LTR Hypomethylated
LTR Hypermethylated
Maternal
Supplements
with
zinc, methionine
betaine, choline,
folate, B12
Or
Genistein
Yellow Mouse
High risk cancer, diabetes,
obesity & reduced lifespan
Agouti Mouse
Lower risk of cancer, diabetes,
obesity and prolonged life
Cooney et al. J Nutr 132:2393S (2002); Dolinoy et al. Envir. Health Perspect 114: 567 (2006)

30. Rickets
Osteoporosis / Osteopenia
Cancer
Skin
GI / Celiac
Mood Disorders
Neurological:
MS / PD / ALS
Cardiovascular
TIGHT JUNCTIONS
Vitamin D Research www.vitamindcouncil.com accessed July 6, 2009

31. Herb-Drug Interactions: CYP3A4
•
•
•
•
•
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Anticancer Agents
Camptothecins
Cyclophosphamide
EGFR-TK inhibitors
Epipodophyllotoxins
Taxanes
Vinca alkaloids
Herbal Products
• CYP3A induction
–
–
–
–
–
SJW
Echinacea
Grape seed
Kava
?Garlic
• CYP3A inhibition
– Gingko

33. Acupuncture

34. Acupuncture for Symptom
Management
• Acupuncture Prevents Radiation-induced
Xerostomia in Head and Neck Cancer
patients (Meng et al 2011, Cancer)
• Acupuncture Treats Xerostomia
• Acupuncture relieves chemo-induced
nausea
• Acupuncture may reduce cancer-related
pain and improve sleep

35. Endorphin Theory

36. “It’s not the load
that breaks you
down, it’s the
way you carry it.”
Lena Horne

37. Stress Response Pathways
Stimuli
Hypothalamus
Anterior Pituitary
Adrenal Cortex
Cortisol
Blood sugar
Epinephrine
Sympathetic
Post-Ganglionic
Neurons
NorEpinephrine
NorEpinephrine
HTN, High Chol
Arrhythmia
Adrenal Medulla

38. Biology of Stress:
Immune/inflammatory
Variables
• Cytokines and Chemokines (such as IL-1
and -, IL-2, TNF-, IL-8, IL-10, and others)
• Nuclear Factors, such as NF-B
• Functional activities of leukocytes, such as
NK cell activity and receptor changes

39. Individual and group mindbody interventions
• Classic examples include: mindfulnessmeditation, NET, Yoga, biofeedback,
qigong, tai chi, expressive arts therapies,
others

40. Mindfulness-based Stress
Reduction (MBSR)
• MBSR is a well-researched, standardized eight-week program
that utilizes mindfulness meditation techniques and gentle Hatha
Yoga to teach participants the skills to better cope with life stressors.
• Learn to be present, in the moment, non-judgmentally. Learn
how to breath, learn how to relax.
• Use mindfulness to facilitate connection to that which has personal
meaning

41. Mindfulness-Based Art Therapy
(MBAT) for Cancer Patients
• Uses standard 8-week mindfulness-based
stress reduction (MBSR) curriculum
• Incorporates playful art tasks that allow
for nonverbal expression of stressful
experiences
• Group format allows for camaraderie and
sharing

42. MBAT Outcomes
Health Related Quality of Life
Figure 2. SF-36 General Health
p = 0.008
Adjusted Mean: Wk 8 - Wk 1
Changes in the General
Health Subscale, on the
SF-36, in MBAT
participants as compared
to wait-list controls.
Adjusted mean
differences for each
group pre and post
intervention are shown (p
= 0.008).
(Monti et al, 2006, PsychoOncology)
15
10
5
0
-5
Treatment
Control
MBAT
-0.59
7.97

43. MBAT Outcomes
Psychological Distress
(Monti et al, 2006,
Psycho-Oncology)
Figure 1. SCL-90-R Global Severity Index
p < 0.001
Adjusted Mean: WK 8 - Wk 1
Changes in the
SCL-90-R
Global Severity
Index in MBAT
participants as
compared to
controls (p <
0.001).
0.05
-0.05
-0.15
-0.25
-0.35
Treatment
Control
MBAT
-0.04
-0.20

44. Desensitizing Distressing
Cancer-related Events
• Objective
To assess treatment effects of Neuro-Emotional
Technique (NET), a 3-5 session, individualized
program for reducing traumatic stress symptoms.
Specific endpoints include:
- Distress and QOL measures,
- Autonomic reactivity
- fMRI imaging in response to stressful cue
- Genomics testing

45. Differences between Post-training and Pre-training resting scans
Monti et al, Stress & Health (2012)
MBAT group (p<0.001)
Control group (p<0.005)

46. Stressor task post minus stressor pre-training program
Monti et al, Stress & Health (2012)
MBAT group (p<0.005)
Control group (p<0.005)

47. NET for Distressing Events
– Distressing cancer-related recollection
lasting at least 6 months
– NET is a mind-body technique that quickly
addresses distress in a few short sessions
– Distressing memory causes autonomic
reactivity
– Our preliminary data shows highly
encouraging results!

48. JeffQuit
- Three week program
- High success rate
-
Study participation costs
less than a week’s
worth of cigarettes!

49. JEFFQuit Smoking Cessation
Study
• Inclusion criteria
– History of cancer diagnosis
– Current tobacco use
– No medical or psychiatric issue
that would interfere with
program participation
– 18 years or older

51. Healthy Living, Healthy You
• Overview
– 8 week program (one hour per week)
– Each session has a nutrition module and
fitness training
– Participants keep daily food journals and
are encouraged to practice exercises
– Evaluate QOL measures and basic
health measures (e.g., weight, BMI) pre
and post program

52. Mastering Food Labels
Commercial Can of Soda
2.5

53. Replacing Bad Fats with
Healthy Ones

54. Sample Exercise- Week 3

55. Ascorbic acid (Vitamin C)
and other nutrients are
being studied at Jefferson
for anti-cancer effects

56. Vit C plus Standard Chemo for
Pancreatic Cancer (Monti et al, 2013)
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•
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•
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Ascorbate concentrations were reached safely
Minimal adverse events attributed to ascorbate
8 of 9 patients with decreased size of primary tumor
Metastases stable or improved in 7 subjects, including all 3 at
highest dose
7 of 9 patients had stable disease by RECIST criteria
Target concentrations of 30 mM ascorbate achieved
Deaths due to advancing underling disease
Ascorbate effects appear more gradual than cytotoxic chemo
Next study step: phase II, longer duration disease progression,
more patients.

58. Thrive throughout
Survivorship
•
An Integrative plan that focuses on improved lifestyle
can have a significant positive impact on survivorship
•
Today we have a scientific basis to modify gene
expression through lifestyle interventions
•
Complementary therapies integrated within a medical
treatment plan can may have a role
•
The Jefferson Kimmel Cancer Center in partnership
with the Jefferson Myrna Brind Center provides a
comprehensive range of survivorship tools

59. Thank you!
No industry support, conflicts of
interest or disclosures to report
daniel.monti@jefferson.edu