latest update 01/14/2025 (work in progress) Notes from lectures from doctors at Memorial Sloan Kettering Cancer Center’s Fundamentals of Oncology Acupuncture.

Integrative Medicine core Lecture Series.

Oncology
Understanding Cancer
The nature of Cancer Cells	Uncontrollable growth
	Spreading to other parts of body
	One cell has a genetic mutation
	Hyperplasia- few few cells grow
	Dysplasia- mass forms
	in situ cancer- tumor (in place, not spread)
	Invasive Cancer- to blood vessel/lymph and spread
Causes	Genetics
	Exposure to harmful elements
	lack of protective elements
	Chance
Cell Cycle	Cell grows- decides whether to continue, replication of DNA-
	Cell prepares to divide- cell division (mitosis).
	a break in this cycle “check and balance” cause cancer.
	DNA-RNA-Protein-> function. Gene mutation cause malfunction
DNA and protein	Dna is the blueprint
	Protein is the building blocks.
Gene mutations	Missense mutation- Dna code for an amino acid- replacement of a single nucleotide-
	Incorrect amino acid which may produce a malfunctioning protein.
	Nonsense mutation- same as above but causing a shortening of the protein.
	One small change creates a whole function change in the cell.
Chromosomes	Normal is 23 pairs, but an abnormal set might have missing, 3, or extra genes.
Mutations	Most of the time, cancer cells harbor multiple mutations. First, second, third, fourth.
	fourth or later mutations become malignant cell.
	Similar, like kid having bad influences like friends, books, movies. Change gradually over time.
	APC mutation
Try to stop early ->	cox-2 over expression (non-dysplastic ACF) anti inflammatory may prevent cancer.
	K-ras mutation (Dysplastic ACF low grade)
	p53 mutation (Dysplastic ACF high grade)
	Loss of 18q (Adenocarcinoma) years to develop
Traditional hallmarks of Cancer	Sustaining proliferative signaling (grow)
	Evading growth suppressors (ignore cell death and keep growing)
	Activating invasion and metastasis (cells that travel on and move)
	enabling replicative immortality (cells that don’t die off when job is finished)
	Inducing angiogenesis (cells that attract blood vessels to grow the cancer with nutrients)
	Resisting cell death (resist immune cells)
	Inducing angiogenesis (cells that attract blood vessels to grow the cancer with nutrients)
Cells of Tumor microenvironment	CSC- cancer stem cell (mother cells)
	CAF- Cancer Associated Fibroblast
	EC- Endothelial Cell
	PC- Pericyte
	CC- Cancer cell
	Ics- Immune inflammatory cell
Emerging hallmarks in Cancer	Avoiding immune destruction- Cancer cells have fake ID that they are good.
	Tumor-promoting inflammation- reduce inflammation
	Genome instability and mutation- genes, proof readers broken
	Deregulating cellular energetics (how cancer use sugars, glucose, to grow) starve the cancer.
Cancer diagnosis	Symptoms
	Physical examination
	Blood tests (cancer markers and proteins that suggest cancer) PSA for example prostate.
	X-ray and Scans
	Biopsy (Gold standard) cells under microscope. Can show how aggressive.
	Biopsy : molecular markers. Ex.- estrogen receptors. Positive with particular dye.
	Type of cancer confirmed by biopsy. Tissue type is more important than anatomical location.
	Where it came from is more important than where it is.
Men most common Cancer	Prostate 27%, Lung 14%, Colon 8%, UB 7%
Women most common cancer	Breast 29%, Lung 13%, Colon 8%, Uterine 6%
Most common cancer Death:	Lung, Prostate, Breast, Colon, Pancreas, Liver, Ovary, Leukemia
Staging	TNM: Tumor Node Metastasis system (Size and amount of lymph nodes involved)
	Stage 0: in situ. Tis, No, mo
	Stage I: T1. no, ,mo
	Stage IIa: T0, N1, Mo, or T2, No, Mo
	Stage IIb: T2, N1, Mo, orT3, No, Mo
	Stage IIIa: t0-2, N2, Mo,or T3, N1-2, Mo
	Stage IIIb: T4, N (any), Mo, or T (any) N3, Mo.
	Stage IV: T  (any), N (any), M1.
	Predicts survival rate of 5 years.
Treatment Plan	Surgery- best chance if caught early. Pain, dysfunction, wound, bowel, nutrition def., self-image (mastectomy)
Chemo	Chemotherapy- kill or suppress tumor growth. Cell cycle chemo drugs:
	G0 and G1: p16, PCNA inhibitors, p21, p53, HDM2 modulators, Selicidib (Cyc202), cyc065
	CDk4/D, Xeloda 5-FU, CDK2/E
	S: Sapacitabine (CYC682), Gemzar cisplatin, CDk2/A
	G2: Camptosar Vepesid
	M: Pik1 inhibitors, other mitotic spindle targets, Aurora inhibitors, Taxol, Taxotere
	Breast cancer: cyclophoshamide, doxorubicin, paclitaxel
	Colon: 5-FU, Oxalipatin, Irinotecan
	Lung: cisplatin, docetaxel
	Ovarian: Carboplatin, Paclitaxel, Doxorubican
	Chemo side effects: Fatigue, nausea, vomiting, poor appetite, constipation, diarrhea,
	low blood counts, neuropathy.
	Most side effects are mild, but 1/4 is higher, low % is severe.
Targeted therapy	EGFR Inhibitors- attack cancer ability to sustain proliferation signaling
	Cyclin-dependent kinase inhibitors- attack cancer ability to evade growth suppressors
	Immune activating ant CTLA4 mAB-attack cancer ability to avoid immune destruction
	Telomerase Inhibitors- attack cancer ability to enable replicative immortality
	Selective anti-inflammatory drugs- attack cancer ability to Tumor-promoting inflammation.
	Inhibitors of HGF/c-Met- attack cancer ability to activating Invasion and metastasis
	PARP inhibitors- attack cancer ability to genome instability and mutation
	Proapoptotic BH3 mimetics-attack cancer ability to resisting cell death
	Aerobic glycolysis inhibitors- attack cancer ability to deregulate cellular energetics.
Personalized therapy
based on cancer genomics	Treatment tailored to the individual patient based on cancer genomic info
	Genomic analysis of tumor samples from a individual patient
	Identification of “driver alterations” that drive cancer growth and spread
	Use of known drugs that attack those alterations as treatment.
Radiation-	Some types of cancer can be cured like lymphoma, but some are resistant
	Side effects: fatigue, local reaction, fibrosis, secondary cancer
Hormonal therapy	Tamoxifen- block the estrogen receptor
	side effects: fatigue, postmenopausal symptoms, sexual dysfunctin, wieght gain, joint/mus. Ache
Immunotherapy	Destroy the immunosuppression characteristic of cancer cell so that immune cells can attack.
Investigational treatment	to test the safety and efficacy of a new therapy in humans
(clinical trials)	clinicaltrials.gov reports 14,889 open studies on cancer as of July 2014
	May hold much promise also with unknown side effects.
Cancer survivorship: 5 year rate	68% all sites since 2003-2009
	Prostate is almost 100% in men
	Breast is 90% in women.
After treatment: road ahead	Symptoms remain, Recovery (mental/physcial), lifestyle change, prevention, wellness.
	Integrative medicine has a lot to offer.
summary	Cancer arises form genomic changes in the cancer cells.
	microenvironment where cancer cells live also plays a important role in how cancer cells behave.
	Cancer is not one disease, but hundreds of diseases based on the profile changes in the cells.
	Some cancers can be diagnosed early and cured. Once spread most types of cancer are not curable.
	Cancer patients have many needs other than just having cancer removed or reduced.
	Integrative medicine can address those needs like reduce symptoms, improve quality of life, and
	promote a sense of well-being.

Cancer Treatment Modalities
Symptom management
Biology of Cancer	Broad group of disease characterized by unregulated cell division and growth
	Malignant tumors are formed and invade nearby body parts and distal sites.
	Causes of cancer are diverse and partially understood.
Cancer Basics	A malignant disease. A series of cellular or genetic changes that cause abnormal cell growth.
	Tumor formation due to uncontrolled cell growth and invasion of the surrounding tissue.
	Ability to spread. Grows and divides quickly.
Treatment modalities	Chemotherapy- systemic treatment, using cytotoxic antineoplastic drugs as standard regimen.
	Biotherapy- treatment working with patient immune system to fight cancer and control side effects.
	Surgery- removal of local tumor
	Radiation therapy- external beam and brachytherapy
	Chemotherapy works by killing cells that rapidly divide. It does kill normal and malignant cells.
	chemo affects cells in the bone marrow, digestive tract and hair follicles.
	this can cause myelosupression, mucostits, and alopecia.
	chemo toxicites: myelosupression, fatigue, nausea, vomiting, diarrhea, constipation
	Anorexia, mucositis, alopecia, “chemo brain”.
Nursing management	Myelosuppression- suppression in bone marrow causing decrease in WBC, RBC, and/or platelets.
	Nadir: point at which lowest blood cell count is reached. 7-10 days after treatment.
	Neutropenia: point at which there is a decrease in neutrophils.**RISK OF INFECTION
	ANC determines if treatment can and/or will continue.
	Anemia- reduction in hemoglobin or RBC’s in the blood. **3rd/4th cycle of chemo.
	thrombocytopenia: lowest point of circulating platelets. *onset of neutropenia.
Myelosuppresson management	hand Hygiene
	Colony stimulating Factors (CSF’s) patients given pegfilgrastim to increase blood.
	Sae food handling- avoid raw, uncooked foods
	Keep plants out of patient rooms
	Prevent trauma to skin and mucosal integrity
	Perform oral care
	Avoid family and friends with cold and flu
	Get flu vaccinations
	Caution with Pet care
	Monitor temperature and notify LIP if fevers
	Monitor lab cultures for bacteria identification and sensitivity.
Fatigue	Most common and long lasting side effect of QOL and ADL
	Fatigue scale
	recurrent progression of disease
	current medications- analgesics, antiemetics, sleep aids
	ROS- malnutrition, insomnia, anxiety, depression, activity, pain, nausea, emesis
	Onset, pattern and duration of fatigue
	Collaborative management and family education
	non-pharmacologic
Nausea and vomiting	Determine the risk factors: single agent vs combination chemo, , metabolic
	physical: GI obstructin, constipation, cranial pressure, anticipatory nausea
	psychological
	metabolical- renal failure, hypercalcemia, constipation
	Pharmacologic management: serotonin antagonists, NK-1 Antagonist, corticosteroid,
	Dopamine antagonists, Anxiolytic.
	Nonpharmacologic management
	Patient/Family education
Diarrhea and constipation	Determine risk factor:
	Chemo/biotherapy?targeted agents
	Radiation therapy- external beam and brachytherapy
	Immunosupressants/Neutropenic sepsis
	Diet/Inflmmatory conditions/Malabsorption/Anxiety/Stress
	Nausea/Vomiting
	Impaction/Ileus
	Hemorrhoids
	Assessment:
	Pattern of elimination
	Level of activity
	medications
	Radiographic studies
	Abdominal pain/cramping
	Abdominal/rectal exam
	Characterisitc of Last BM: quality, formed
	Diarrhea Management:
	Monitor Stool number, amount, consistency
	Replace fluid and electrolytes
	administer antidirrheal medications
	Patient/family education
	Constipation management:
	Laxative options
	Non-pharmacologic interventions
	patient/family education
Anorexia	the abnormal loss of appetite for food that can result in loss of adipose and muscle tissue.
	Pathophysiology- change in taste of food, metabolic, tumor on gastro-intestinal tract.
	Risk factors:
	Advanced tumor- gastro-intestinal, Lung
	Solid tumor
	Chronic Illness= CHF, Pulmonary disease
	Multimodal Therapies
	Clinical manifestations- involuntary weightloss greater than 5%.
	Patient/Family Education- dietary consults, supplementation
Mucositis:	Risk factors, Clinical Manifestations, Oral assessment.
	Management: Prevention, Treatment, Hygience program.
	Changes in Taste, difficult swallowing.Edemas, ulceration.
Alopecia	Most visible sign. Head, eyebrow, eye lash, pubic hair.
	Risk Factors:
	Agent received
	High dose Chemotherapy
	Comorbidities
	Nutrition Status
	Radiation therapy
	Clinical Manifestations- expercted time frame to Alopecia
	Patient/family education
Chemo Brain	Cognitive changes based on therapy: concentration, attention, language, motor skills, learning
	memory. Stress, anxiety, depression.
	Risk Factors: Age, psychological factors, fatigue,
	Regimens: multimodal, dose intensity, cumulative effects
	Patient family education: acknowledge and validate, practical solutions.
	Neurotoxins, white matter damage to brain, Dna damage, cytokine increae, hormonal
	Increase sleep intervals, regular exercise, regimented daily planning.
Goal of chemotherapy	Cure: prolonged absence of disease
	Control: preventing the growth of cancer cells without the complete elimination of disease
	Palliation: comfort measures and/or reduction in side effects and symptoms.
Principles of Cancer therapy	Adjuvant: therapy following primary treatment (surgery, RT)
	Neoadjuvant: use of one or more treatment modalities prior to primary therapy
	example: chemo or radiation before surgery.
	Chemoprevention: treatment ot prevent cancer in  high risk patients.
	Myeloablation: Obliteration of bone marrow in preparation for Stem cell or bone marrow transplant
Combination vs Single agent therapy	Combination of agents with different mechanisms of action is able to increasee the
	proportion of cells killed at any one time.
	Combination chemo reduces the possiblilty of drug resistance.
	Agents used in combination chemotherapy have proven efficacy as single agents.
Measuring tumor response	CR: Complete response- removal of tumor confirmed after one month.
	PR: Partial response- half mass gone in one month.
	SD stable disease- reduction of tumor mass is less than 50%.<25% increase in new tumor growth.
	PD progressive disease- 25% growth in new disease and or new tumors.
	Relapse: a new tumor appears or original tumor reappears.
Dosing Chemotherapy	Most cytotoxic chemotherapy drugs are dosed based on BSA (body surface aea).
	BSA is the estimated total area of a persons skin expressed in square meters (m2).
	BSA is calculated using current and accurate height (cm) and weight (kg).
Patient Education	Ensure patient and family understand meaning of “cycle” in chemotherapy.
	usually chemo 2 cycles every two weeks, twice per months, or 6 months thereafter.
	Total of 12 cycles.
	Avoid interruption in treatment cycles, planning around vacations and events.
	Encourage participation in care.
	Explain diagnosis and treatment
	Explan potiential side effects of treatment
	Explain signs and symptoms to report
	identify available resources
Biotherapy	Biologic therapy and Immunotherapy
	Purpose: uses the body’s own immune system to fight cancer
	and to reduce treatment-related side effects.
	Help cells damaged by treatment, reprogram cells.
MoAbs )Monoclonal antibodies)	Produced in lab: designed to bind to the antigens on malignant cells
	Block the growth of the tumor and/or recruit the body’s immune system to attack cancer cells
	Can be given as a montherapy, in combination with chemotherapy, and with other targeted
	therapies under clinical trial.
Types of MoAbs	Human- umab
	Murine- momab (mouse)
	Chimeeric – ximab (human and mouse)
	Huamnized -zumab (human and mouse)
Mechanism of action	Specific protein binds to specific receptor on cell surface
	When antibody binds to recepto, all downstream signaling is halted.
	Cell apoptosis
Monitoring patient on MoAbs	Hypersensitivity Reactions
	Aggressive IV hydration
	Monitoring electrolyte imbalance every 6 hours and replacements as needed.
	Monitor cardiac status as required
	Acneform rash.(not acne, nor do not use acne OC drugs, just report to doctor)
Surgery-	localized
	preventive
	diagnostic
	Staging
	Debulking
	Curative- mastectomy example
	Palliative- repair of a side effect
Surgical complications	Pain, Atelectasis (inadequate breathing)
	Blood clots, fatigue, muscle atrophy, anesthesia effects, confusion, infection.
Radiation therapy-	High dose of radiation to kill cancer and stop spread
	routes: external beam, internal
	60% of patients get radiatin to treat and reduce symptoms
Transplants	hematopoietic stem cell, Bone marrow.
	Myeloablative and Nonmyeloablative
	Allogeneic- donar. Luekemia, lymphoma, myeloma, aplastic anemia, thalassemia, immune def.
	Autologous- self. Hodgkins, non-hodgkins, myeloma, testicular. Stem cell harvest. cytoxan.
	Cord Blood- umbilical cords and placenta

Breast Cancer	> 1 million breast cancer new cases. Global health burden.
	Most common in USA women 240,000 new diagnoses expected in 2014
	>40,000 deaths from breast cancer in US each year.
	Most frequently diagnoses cancer amoung women each year.
	Incidents increase with age and peaks between
	2nd leading cause of cancer death in women in the US. 15% in 2010.
	Death rates have declines since 1991 by more than 30% due to early detection and treatment.
	2005 Berry NEJM study shows that from 1975 to 2000, the rate of death was lowest per 100k women:
	If they had Screenings and Adjuvant Therapy. Survival was lower with just one or none.
	Adjuvant as chemotheraoy, Hormone therapy, Anti-body therapy, and Radiation treatments.
Declining Deaths	Early detection yields more but small tumors
	Better therapy: Broadened use of Tamoxifen, AI’s, (Aromatase inhibitors)
	Surgery, and Antiresorptive bone agents. Chemotherapy. Trastuzumab, Radiation.
	Good news: incidents and mortality decline, early diagnosis is cureable.
	Challenges: Early stage breast cancer can still have distant recurrence,
	metastatic breast cancer  is treatable but not cureable. (Stage IV)
Breast Cancer:	normal ducts begin to have Atypical Hyperplasia, then DCIS, (Ductal Carcinoma in situ)
	lastly cancer invades other tissue. Invasive ductal Carcinoma.
Risk Factors:	Gender, age, Race, Genetic (BRCA1, BRCA2), personal history of breast cancer
	Early menses and or late menopause, hormone therapies, late or no pregnancies,
	family history, dense breast tissue, Lifestyle: alcohol, smokng, obesity, exercise, diet.
BRCA testing	If known mutation in the family, close relative with breast cancer <35 yo,
	multiple early onset or bliateral breast cancer, ovarian or fallopian tube cancer, pancreatic cancer,
	ashkenazi jewish ancestry, any history of cancer in family.
Detection	Mammogram year age 40 and up.
	Clinicla breast exam- every 3 years before age 40, annually after 40.
	Breast self exams, ultrasound, Breast MRI
Biopsy	Fine needle aspiration- remove fluid from cyst.
	Core needle biopsy- blind, image guided, sterotactic, cells removed from lump with needle.
	surgical biopsy- tissue removed.
Staging	tumor size, local or multiple lymph node metastasis
	Are brain, lung, liver, bone affected?
	0- small, no lymph involvment, no spread, survival 100%
	I- 2cm, No lymph, no metastasis, 96% survival
	II- 205 cm, yes or no lymph, No spread, 84% survival
	III- >5cm yes lymph involvement, No spread, 52% survival.
	IV- metastasis yes, survival 24%.
Treatment strategies:	Early- surgery, XRT (radiotherapy)-systemic, goal is to cure.
	Locally advanced- systemic, surgery, XRT, , cure and improve local control
	Metastatic- systemic and XRT, palliative treatment.
Modular substyles:	HR+/HER2- (luminal A) 505, indolent (bone, soft tissue), tx: endocrine agents
	HR+/HER2+ (luminal B) 10-15%, aggressive (visera), tx: antiHER2 and endocrine agents, chemotherapy
	HER2+/HR1 (HER2+), 10-15%, very aggressive (viceraa and CNS), antiHER2 agents and Chemotherapy
	Triple Negative (basal-like), 20%, very aggressive (viscera and CNS), Chemo and platinums promising
	BRCA 1 or 2 mutation, <5%, moderately aggressive, chemo (platinums) and PARPi promsing.
Theraputic options and outcomes	Chemo: ER/PR negative, visceral mets, faile dendocrine therapy
	Endocrine: ER and/or PR postive
	Trastuzumab, Pertuzumab, TDM-1, Lapatinib: her2/Neu-postive
	Bevacizumab: HER2/Neu-negative, first-line therapy
	RANKL inhibitors, Bisphosphonates: Osteolytic bone mets
Selected Toxicities with therapy
	endocrine therapy- hot flashes, vaginal dryness or discharge
	Bevacizumab- hypertension, throbembolic disease
	Trastuzumab- Cardiac Dysfunction
	Lapatinib- diarrhea, dermatologic
cytotoxic agents	Anthrocyclines- caridomyopathy, alopecia
	Paclitaxel- neuropathy, alopecia
	Docetaxel- fluid retention, hyperlacrimation
	Ixaqbepilone- neuropathy, fatigue
	Eribulin- neuropathy and fatigu
	vinorelbine- Obstipation, neuropathy
	Capecitabine- hand-foot symptoms, diarrhea
	Gemcitabine- fever, flu-like symptoms
Metastatic Breast Cancer (MBC)	Balance Efficacy (survival) vs Toxicity (minimal toxicity)
	Take into consideration Disease characteristics and patient characteristics.
	ER/PR+: hormonal-treatient patient- first line, second line, and third line hormonal treatments.
	ER/PR-: chemo related: HER+ based chemo, first, second, and thrid line
	Triple negative ER/PR, HER-: chemo first, second and third line.
	HER- (ER/PR+): chemo, first, second, and thrid line.
	Trastuzumab- essential part of Rx of HER2+ MBC. Chemo plus Trastuzumab decreased cancer progression.
	Marine sponge Halichondria Okadai (Eribulin Mesylate, E7389) target agent, blocks mircortubule.
	MBC median survivial is 3 years, incruable, but tx is to extend life and qulity of life.
	MBC- hormonal therapy is tolerated and frequently recommended for women whith hormone
	responsive MBC andnot at risk for visceral crisis.
	Chemo is for women with hormone-refractory disease, hormone receptive negative disease,
	rapidly progressive or significant cancer-related symptoms.
MBC treatment considerations	Age, preference, co-morbid conditions, performance status, ER/PR status, HER2 status,
	disease-free interval, prior adjuvant therapies, number and distribution of metastatic sites,
	potiental of viseceral crisis, Bone metastases need biophosphanate therapy, Palliative XRT for pain.
Early stage Breast Cancer	Breast Conserving- cancer and local nodes removed in axillary
	Simple Mastectomy- breast and local nodes removed in axillary
	Modified Radical Mastectomy- all removed.
Pathology	In Situ: ductual carcinoma in Situ and Lobular carinoma in Situ. Benefit is local control.
	Inflitrating Carcinomoa- infiltrating ductal and invasive lobular, Benefit: systemic control.
systemic recommendations	Axillary nodes, tumor size, histologic grade, Estrogen and progesterone receptiors HER2/neu status.
Oncotype DX 21 gene recurrence score	low risk: RS < 18
	Int rist RS >18 <31
	High risk >31 (benefit from chemotherapy)
Adjuvant Chemo regimens	CMR- cyclophosphamide, methotrexate, fluorouracil
	AC- doxorubicin, cyclophosphamide
	CAF/FAC: doxorubicin, cyclophosphamide, flourouracil
	FEC/CEF: epirubicin, cyclophosphamide, flourouracil
	A->CMF: doxorubicin, cyclophosphamide, methotrexate, flourouracil
	AC- Paclitaxel
Emerging therapy PARP	PARP as a target, key regulator of DNA damage repair, binds directly to DNA damage and
	produces large branched chains of poly (ADP-ribose)
	it is differentially upregulated in primary breast cancers including ER-, PR-, and HER2- subtypes.
Lung Cancer
Epidemiology	2nd most common cancer in Men and Women, Number one in death in both
Causes and risk factors	Tobacco smoking, 85-90% of all lung cancer-related deaths.
	Smokng cessation: former smokers who had quit >15 years had 80-90% decrease risk versus current smokers.
	former smokers continue to have a 10-80% higher risk than never smokers
	Ongoing smoking by early stage patients have increased likelihood of all-cause mortality, tumor recurrence, and
	development of a secondary primary tumor.
	Second hand smoke- 15-35% of lung cancers due to second hand smoke, increased risk if exposed prior to age 25.
	Occupation/environment: asbestos, radon, cooking from coals.
	Benign Lung disease- COPD, chronic bronchitis, pneumonia, tuberculosis
	Radiation: breast and hodgkins disease patients have increased risk
Lung Cancer screening	NLST (National Lung Screening Trial) 2013 data:
	The 3 year trial, enrolled asymptomatic participants age 55 – 74, 30 pack-year history.
	Randomnized to low dose CT vs. chest Radiography
	Conclusion:  although there was low positive predictive value with low dose CT,
	more early stage cancers were detected as compared to chest radiography.
Role as mid-level practitioner	Clinic, Operating room, post-operative floor
	History, physical exam, findings, plan. Mid-levels allow for great amount of patients to be seen in clinic and operating room.
	It provides more provider-patient face time as visits are split between attending NP/PA.
	Helpful in academic setting with assisting in education of rotating fellows and residents.
Cliic presentation	SX: couth, weight loss, dyspnea, chest pain, hemoptysis, bone pain, hoarseness.
	Symptomatic patients often represent advanced stage of disease.
	Early lung cancers are often found incidentally.
	Metastatic disease of primary lung cancer: common sites- brain, bone, liver, adrenals, skin
	sx: weight loss, fatigue, night sweats, loss of appetite.
Diagnostic imaging	chest x-ray, CAT scan
	example: Squamous cell CA (cancer) RLL CXR in rt. Lower lobe
	AdenoCA in Situ. downward scan.
diagnosis and Staging	Most imporant part
	Role of CT surveillance: if nodule found, wait, they may have infection or inflammation, try antibiotics first and rescan 6 weeks.
	Work ups:
	Biopsy: CT guided vs. VATS wedge. If not shrinking.biospsy to pathologist.VATS: video assisted thoracic surgery biopsy.
	Recent CT scan, with IV contrast is best. IV contract to see if vessles are attached to tumor.
	PET Scan- show if nodule is lighting up. If spreading, or gone to lymph nodes. If lymphs are medial or distal, determine treatment.
	MRI Brain- more useful in stage II or higher. PET scans only scan neck down, MRI needed for brain.
	Other testing for pre-operative risk assessment:
	Pulmonary function tests
	VQ scan
	Cardiac risk evaluation
Types of Lung CA: NSCLC vs SCLC	Non-small cell carcinoma vs Small cell carcinoma
	Histology Data:
	Ademonocarcinoma: 38%
	Squamous cell 20%
	Large Cell 5%
	Small Cell 13%
	NSCLC NOS 18%
	Other 6%
	Pathology Data:
	Large cell 2%
	Adenosquamous 1%
	Adenocarcinoma 72%
	Squamous cell 25%
	Increasing incidence of adenocarcinoma with corresponding decrease in other NSCLC and SCLC.
TNM Staging	Metastases: M0: absent. M1: present
	Lymph Node (N). N0, N1, N2, N3. +positive, -negative in following regions:
	Supraclavicular
	Scalene (ipsi/contralateral)
	Mediastinal (ipsi/contralateral)
	Subcarinal
	Hilar (ipsi/contralateral)
	Peribronchial (ipsilateral)
Stage 0	No Tis (Carcinoma in situ) N0 (no lymph nodes affected), M0 (metastasis absent).
Criteria	Primary Tumor (T) a. size, b. endobronchial location, c. local invasion, d. other
Stage 1A, Stage Iia	T1, a,b,c, no invasion proximal to the lobar bonchus, surrounded by lung or visceral pleura.
	< 3 cm
Stage Ib, Stage Iib	T2: a.b.c.d , main bronchus, viseral pleura, atelectasis (collapse), obstructive pneumonitis, hilar region, but not entire lung.
	> 3 cm
Stage Iib	T3 (a and c)/b/d. main bronchus, chest wall, diaphragm, mediastinal, pleura, pericardium, atelectasis, entire lung.
	any size
Stage IIIb	T4: (a and c) /d. mediastinum, treachea, heart, great vessles, esphagus, vertebral body, carina (cartilage of branchia)
	Malignant pleural, pericardium effusion, , satellite tumor, ipsilateral primary tumor lobe of lung
	any size
Stage IV	M1 (and T, any N)
Treatment
Stage I	surgery
Stage II	a lymph is involved, surgery, tumor and lymph node, systemic chemo in some cases.
Stage III	7 cm and several lymph nodes
	TX: no single approach, surgery with chemo, chemoradiation
Stage IV	tumor on both lungs, lymph involvement, spread to none, brain, liver, adrenal
	tx: chemotherapy, palliative radiation therapy.
NSCLC: Non surgical management	Radiofrequncy ablation- fry the cells. Radiatin therapy: EBRT, SBRT, chemotherapy- single agent, combination, targeted.
	Platinum agents (cisplatin, carboplatin), taxanes, (paclitaxel, docetaxel).
	Combination therapy (Bevacizumab, Crizotinib, Cetuximab)
Operating room	PA/NP role: operating oppoiste attending and fellows, responsible for post op orders.
	Smaller staging precdures: EBUS-TBNA or Endobronchial ultrasound, Transbroncial needle aspiration
	mediastinoscopy
	Major lung recection operations: minimally invasive versus open wedge resection,
	segmentectomy, lobectomy, pneumonectomy.
Mediastinoscopy	classic stagin procedure that uses small incision at sternal notch, can sample paratracheal and subcarinal lymph nodes, low M&M,
	100% specificity, higher sensitivity when preceded by CT/PET.
	Useful when larger samples are necessary, molecular profiling, lymphoma.
EBUS-TBNA	Real-time imaging of peri-bronchial structures and needle biopsy of lymph nodes.
	Access to paratracheal subcarinal and hilar LN. Better accuracy, less time, fewer biopsies.
Major operations	VATS, Open thoractomy, Robotic assisted VATS
	Lung wedge resection- for suspicious nodule, can proceed to lobectomy if malignant, most often perfomred VATS.
	Segmentectomy, lobectomy: anatomical resection of lung lobe or segment of lobe. Receommended for early
	stage tumors, NSCLC stage I and II. Can be performed via open thoracotomy, VATS, pr robotic VATS.
	Thoracotomy morbidity 45%, mortality 3.6%
	VATS morbiditiy 28%, mortality 0%.
Lobectomy vs limited resection	wedge resection not recommended for stage 1 patients.  Lobectomy still best surgery for overall survival in good risk patients.
	Segmentectomy reasonable for tumors <2cm. Lobectomy for tumors > 2 cm and stage 1.
	High risk patients should be considered for segmentectomy regardless of tumor size.
Pneumonectomy	removal of entire lung, must be strongly clincally indicated and patient must have pulmonary reserve.
	Significant mortality between 5-10%. Reasonalbel for certain T3 and T4 tumors without nodal disease.
	Indications: Proximal bronchial tumor. Adjactent to right upper lobe orifice. Tumor extends across major fissure.
	Prior resection of other ipsilateral lobes resulting in completion pneumonectomy.
Malignant pleural effusions (Iv)	Pleurodesis- scarring of parietal pleura so as to form adhesions.
	insertion of pleurx catheter-drain the effusion. Patients can learn how to drain at home.
Post-op floor care	Prevention, early identification, early treatment of cardio-pumonary complications
	Most complications occur within first 3 post-op days.
Monitoring:	consciousness/alertness- inappropriate analgesia, hypoxia?
	Fast or shallow respiration, underlying atelectasis?
	Daily CXR- as long as chest tube continued
	Chest tube: airleaks? Amount? Bloody? Milky?
	Periodic assessment of wound dressing.
	Hemodynamics essential to status of patient: HR, BP, UOP, O2 saturation.
	Prophylactic interventions for thoracic surgical complications: pain control, deep breathing exercises, effective cough, ambbulation.
	Pneumonia risk.fevers, WBC, mucus. Sputum culture, cephalosporin ABX.
	chest PT, POPP patient education for post-op risks and complications.
complications	Cardia arrhythmias: AF, atrial flutters, paroxysmal atrial tachycardia.
	tx: low does RTC IV metoprolol or Dilt gtt. Patients with cardia history, older than 65.
	Prolonged air leaks and post-op spaces- can dissipate within 1 week.
	Empyema- infected loculated parapneumonic effusion. CT to evaluate, ABX therapy and drainage.

Prostate Cancer	Many men will get prostate cancer 14% of all new cancer cases in US
	A fraction of these men will die of the disease, or suffer from it.
	It is the second leading cause of cancer related death in American Men.
	Minority men have a higher risk.
	Overtreatment- incompetence and erectile dysfunction
	PSA screening: PSA is not cancer specific, only prostate specific. Benign prostate issues occur, just not cancer.
	Specific overlap between BPH and cancer
natural biological PSA variations:	Patient age and prostate volume
	Prostate cancer
	Prostatic inflammation
	Race/ethnicity
Screening paradox	Increase detection rate but did not prevent deaths. 22% more cancer in the screening group.
	Family history of prostate cancer should be considered.
	Risk assessment: death from prostate cancer, death from other causes, Quality of life- over and under treatment
	Risk of disease are gauged by: stage, Gleason score, PSA.
Staging	T1
	T2
	T3
	T4- invading other structures
Bone disease	Is the central issue of treating metastatic prostate cancer
	Primary source of morbidity and mortality
	It is the most feared complication of cancer: cord compression, marrow failure, pain, fracture, death.
Gleason Score	Grade 1 to 5. Dominate and lesser population. Example 4+4 + 8.
Paradox of reasonable  choices	surveillance- serial monitoring of the cancer without treatment
	radiation therapy- external beam or seed placement
	Hormones or no hormones
	Surgery:  radical prostatectomy
High risk disease	Risk of treatment failure regardless of modality
	Risk of metastatic disease and risk of death.
	High Gleason score does not need surveillance, they need treatment to prevent spread.
Hormones	Testosterones and DHT are fuel for prostate cancer growth.
	Hypothalamus- LHRH – pituitary- ACTH to adrenals and FSH and LH to testes.
	Adrenals- androstenedione DHEAS, DHEA- testosterone, Estradiol
	Testes- androstenedione testosterones (T) and Estradiol.
	Adrenals and testes- SHBG, (T) 5 alpha reductase- DHT  – AR- Protein synthesis- Prostate cell.
	Flutamide Bicalutamide Nilutamide- inhibit testosterone and androgen receptor. Enzulutamide
	Ketoconazole- reduce testosterone in adrenal and testes and tumor. Arbiraterone.
	Orchiectomy Ketoconazole-
	Finasteride- reduces 5 alpha reductase.
	Leuprolide Goserelin- LHRH production reduce drug. GnRH antagonists
Prostate Cancer Clinical states	Castration Sensitive-
	clinically localized disease -> Rising PSA: castration sensitive-> Clinical metastases or Rising Castrate Resistant
	Castration Resistant-
	Rising PSA: castrate resistant- > Castration sensitive metastatic _. Castration resistant 1st line -> mCRPC 2nd line.
Progressive prostate cancer	No Cancer-> Localized disease -> Rising PSA -> Castrate sensitive metastatic -> CRPC metastatic
	tx: lower testosterone agent at localized disease stage.
Early vs Defeered hormones	MRC- primary therapy for localized /met
	Messing- adjuvant, N1
	Bolla- adjuvant, high grade T3, 4
	85-31- adjuvant, T3 or N1
Early Hormones	Early bisphosphonates for bone wasting
	Early therapy for impotence
	Early SSRI’s for hot flash and depression
	Early Breast RT for gynecomastia
	Early cholesterol and glucose and weight management
Intermitten Hormal therapy	PSA high 45_> lower to 0 with hormone therapy- > take a break -> if psa gets up like 20 range _> repeat hormone therapy.
	do chemo and radiation while on hormone T blockers if PSA is high again.
Castration resistant	resistant to testosterone lowering agents.
	It is still exquisitely sensitive to testosterone and DHT.
Adrogen receptor (AR)	receives hormones that fuel the growth of cancer tumor by way of either AR mutations, AR overexpression ,
	or copious androgens within the tumor. It might be adrogen sensitive, or finding other sources of androgen in the body.
Reduce the adrogen abiraterone	Cholesterol with Desmolase
	Pregnenolone-> progesterone-> deoxy-corticosterone -> Corticostero -> Aldosterone
	CYP 17a-hydroxylase for Pregnelone
	11b-hydroxylase for Deoxy-corticosterone
	17a-OH-pregnenolone -> 17a-OH-progesterone -> 11-Deoxy-cortisol ->Cortisol
	c17, 20-lyase to block 17a-OH-pregnenolone
	DHEA -> Androstenedione -> testosterone -> DHT or ESTRADIOL
	CYP19: armomaatse to stop DHT and Estradiol
Abiraterone and mCRPC	abiraterone 1000mg daily and prednisone 10 mg daily
	hormonal therapy could prolong survival in men with metastatic castration resistant disease by 35%
AR overexpression	Enzalutamide
	Enzalutamide is an oral investigation drug rationally designed as a new hormonal agent to target androgen receptor (AR) signaling,
	a key driver of prostate cancer growth.
	Enzalutamide- first in new class of AR signaling inhibitors that affect multiple steps in the androgen receptor signaling pathway.
Enzalutamide for mCRPC	mCRPC- Castration resistant prostate cancer
	mDV3100- 180 mg daily vs.
	Enzalutamide 160 mg daily. Overall survival was higher with this drug.
	good for both pre and post chemotherapy. Risk reduction for death.
Alliance A031201	Enzalutamide 160 mg, Abiraterone 1000mg, prednisone 5 mg
Hormones for prostate cancer	AR is active thought the natural history of the disease.
	“Hormonal therapy” covers a band swath of anti-AR approaches- survival data for both castration sensitive/resistant disease/
	Both ligand reduction and anti-AR approaches
	No other modality has had as broad an application or as clinically beneficial results for such a large group of patients.
Bone tumor	pain, fracture, disability, blood dyscrasias, neurologic compromise, death.
	deposited calcium and phosphate crystal on new bone, bone deposition, new layers of bone where the cancer is.
	new bone gets over deposited.
Radium-233 targets bone metastases	radium 233 acts as a calcium mimic. It is a earthy element on the periodic table.
	Naturally targets new bone growth in and around bone metastases
	Radium 233 is excreted by the small intestines.
	Low rate of damage to the bone and marrow, increases quality of life with little or no side effects.
Immunotherapy	Sipuleucel-T: WBC from blood, collected and exposed to prostate proteins and injected into prostate.
	It is a kind of vaccine therapy.
Chemotherapy	Taxanes. Taxus baccatus.
	Cabazitaxel
	Docetaxel
	Many men will go right to chemo if disease is first found to be metastatic. Then hormone therapy is introduced.
Conclusion	Prostate cancer represents a wider spectrum of risk than most other cancers
	Good decision making relies on a adequate understanding of risk of disease, risk of therapy, and risk of patients other diseases.
	Substantial advances in what was previously an untreatable condition, mCRPC, now is substantially bending the
	survival curve of prostate cancer. Improving overall survival and quality of life.

Gynecological Cancers	normally done by gynecological surgeons with chemotherapy
	MSK- separate surgeons and medical oncologist
Gynecologic Cancers- New cases	15% Uterine Cervix
2014 study	56% Uterine Corpus
	23% Ovary- *diagnosed late and not curable
	5% Vulva
	3% Vagina
Death Rate:	14% Uterine Cervix
2014 study	30% Uterine Corpus
	49% Ovary*
	4% Vulva
	3% Vagina
Ovarian Cancer	Age, Family Hx (BRCA-1 (80-90% risk), BRCA-2),
	Ovarian Hx (Age of menarche, Use of birthcontrol (OCP oral contaceptive), Gestational Hx, age of menopause)
	BRCA- removal of ovaries age 35 and up.
	OCP and having babies decrease risk.
Origin	Tubes, presentation: insidious, non-specific
	bloat, change in bowels, urinary frequency, delay in diagnosis.
	Dx: CT scan and Biopsy/Surgery if suspected.
Surgery	Staging and debulking (remove as much of tumor as possible)
	Midline Laparotomy_. Hernias
	Surgical gynecologic oncologist
	Optimal vs sub-optimal
	Upfront (surgery right away) vs Interval (chemo then surgery)
	Secondary, tertiary (additional surgeries later)
Stage	Stage I- just in ovary
	Stage II- spread to pelvis
	Stage III- spread into abdomen
	Stage IV- Liver, Lungs
	75-80% are diagnosed at stage III/IV
Histology (Ovarian cancer types)	75% high grade Serous
	Endometroid
	Low grade Serous
	Clear Cell
Ovarian Cancer Chemo	6 cycles: Taxol or Docetaxel. Once every three weeks.
	then: Carbo or Cisplatin (paltinum). (2 different drugs will be used like taxol, then carbo)
	IV vs IP (this port goes to abdomen)
	Mediport- a port direct into the veins
After chemo then what?	Remission/Replapse/Resistance
	Primary therapy- cure: complete remission.
	Primary therapy- refractory/persistent disease. (Grave prognosis)
	Remission- chemotherapy
	Resistance to chemotherapy-
Relapse	Rarely curable, survival for many years
	Many rounds of chemo with side effects: neuropathy, chemo-brain, diarrhea, constipation, fatigue. Alopecia, rash.
	Repeat surgeries- hernias, bags, tubes.
	Fatigue- chemo, anemia, lack of sleep. Chemo-brain- forgetful, depression, losing items, etc.
Chemo-	Carbo-Taxol:side effect: make WBC, RBC count lower, causing anemia and fatigue. Bowles, hairloss, neuropathen.
	Liposomal Doxorubicin: hand-foot, mucositis
	Hand foot syndrome- drying, peeling of hands and feet. Mucositis- dry mouth.
	Topotecan: Fatigue, Cytopenias
	Cytopenias (more than one kind of anemia, low blood cell count)
	Gemcitabine- fatigue, cytopenias, fever, inflammation
	Bevacizumab- sorethroat, nose bleed, headache
Ovarian cancer complicaitons	Clots, DVT, PE (pulmonary embolism)
	Edema, Ascites (fluids in abdomen), Effusions (fluids around lungs)
	Bowel Obstruction. Colostomy, Ileostomy, Stent. Drainage PEGs
	Kidney blockage
	Brain METS
	Liver Failure
	Lung METS
Ovarian cancer consequences	Pain, fatigue, malnutrition, Depression/anxiety, economic/work, social/sexual, physical/cognitive impairment
	effects on caregivers/families, disability, death.
Cervical Cancer	average age 48, Hi risk is HPV, tobacco, HIV+
	PAP smear screen reduces risk.
	HPV- cervix cancer, Oropharynx cancer, Anal cancer, Vulva cancer, Vaginal cancer, penis cancer. 32,000 per year.
HPV vaccines	Gardasil – recombiant VLP: capsid protein L1
	HPV 16,18 (70% CxCa and some H and N)
	HPV 6,11 (90% Genital warts)
	Cervarix- recombiant VLP: capsid protein L1
	As04 Adjuvant, HPV 16,18 (70% CxCa and some H and N)
	Girls routine 3 does age 11-12, catch-up vaccine age 13-26
	Boys age 9-21
Origin	CIN-III
	Presentation- abnormal PAP, bleeding, pelvic pain, Urinary Sx.
Staging	Ia,b: at cervix
	IIa,b: getting into surrounding tissue like vagina or outside cervix (parametrial tissue).
	IIIa,b: getting into surrounding tissue  outside cervix, pelvic floor, bone, pelvic sidewall.
	IVa,b: moving into rectum and more.
	work-up: bimanual, EUA, PET/CT, MRI
	Urine cytology, Renal U/S.
	usually chemo and raditation without surgery.
surgery	Radical Hysterectomy
	Trachelectomy
Radiation	Pelvic radiation 28x external beam and brachy
	side effects: fatigue, diarrhea, cytopenias, cystitis, lymphedema, colitis, second cancers (rectal, leukemia), nausea/vomiting.
	5 1/2 weeks daily.
Cisplatin with RT	fatigue, constipation, nausea/vomit, cytopenias, electrolyte disturbances, Ototoxicity, Dehydration, kidney damage
	tinnitus, hearing loss.
Relapse	Less response to chemo.
Complications	Pain, clots, DVT, edema, bowel obstruction, kidney blockage, ureteral stents, Lung Mets.
Consequences	Pain, fatigue, malnutrition, Depression/anxiety, economic/work, social/sexual, physical/cognitive impairment
	effects on caregivers/families, disability, death.
Enometrial Cancer	Type 1: Obesity, DM-2, Estrogens, Tamoxifen
	Type -2: Genes HNPCC, BRCA-1, Tamoxifen
Staging	Type1: post-menopausal bleeding (PMB), , typically found early
	Type 2: PMB or Mets, can metastasize quickly
	Stage I: uterus lining
	Stage II: uterus lining and into connecting tissue
	Stage III: uterus, connecting tissue, cervix
	Stage IV: uterus, into fallopian tube, and ovaries, ligaments more.
Surgical-	removal of uterus and tubes, lymph node sampling
	Omentectomy, tumor debulking, washings.
	Adjuvant RT and or chemo- depends on stage and aggressiveness.
	Radiation: IVRT (bradytherapy), WPRT (External beam)
	Chemo: +/- Cisplatin with RT.
	chemo only: Taxol and Carboplatin
Recurrence	Radiation: WPRT , if limited to pelvis and no prior RT
	Chemo- metastatic disease, non-curative, carbo-taxol, Bevacizumab, Anthracyclines.
Hormonal therapy	Megesterol- blood clots, weight gain, hyperglycemic
	Tamoxifen
	Aromatese inhibitors
Complications:	Clots, Edema, bowel obstruction, Kidney blockage, Liver failure, Lung mets, Bone mets
Consequences:	Pain, fatigue, malnutrition, Depression/anxiety, economic/work, social/sexual, physical/cognitive impairment
	effects on caregivers/families, disability, death.
Rare gynecologic cancers	Vaginal, Vulva, Sarcoma, Carcinosarcoma, germ cell, GTD, Small Cell, Granulosa Cell.

Supportive Care for Cancer patients
Integrative Stratagies	anxiety, stress, chemo brain, constipation, depression, diarrhea, dry mouth, headaches. Hot flashes
	insomnia, immune suppression, loss of appetite, loss of libido, Lymphedema, mouth sores,
	nausea, vomiting, pain, neuropathy, radiation burns, shortness of breath, urinary retention, incontinence
Oncology in TCM	modern disciple, combines classical theory with modern technology and research
	腫瘤 Zhongliu
	瘤 Liu (tumor)
	腫 Zhong (swelling)
	Accumulation of flow of blood generated a “swollen tumor” Liu Zhong
Modern theory	Cancer (癌 ai) is understood as
	正虛邪氣
	zheng xu xie shi • Vacuity of right qi, repletion of pathogenic qi
TCM and Western oncology	Developed over last 5 decades.
	In China, routine to use both (over 90%). China is heavy on herbal formulas.
	In the US, modality of acupuncture is most common in oncology.
Key points:	Cancer is often seen as a local manifestation of underlying constitutional disease.
	Weaking of resistance in the body, while oncological factor grows.
	Goal not necessarily to eliminate cancer, but to increase quality of life.
	TCM may suppress cancer growth, promote cancer cell apoptosis, antiangiogensis, and antimetastasis.
	May help prevent relapse.
Treatment Continuum	1. Initial diagnosis
	2. As enter and during treatment
	3. Recovery after treatment
	4. Additional rounds of treatment
	5. Transition off-therapy
	6. Surveillance
	7. Long-term recovery to prevent relapse and metastasis
	8. End of Life Care.
Why patients see care.	Reduce stress of illness
	Improve Quality of Life
	Symptom care management
	Prevention of late effects
	Prevention of second malignancy and relapse
	Treatment of Cancer “Try everything possible”.
Key points:	Treatment will combine WM diagnosis and TCM syndrome differentiation.
Treatment planning:	patient constitution
	TCM syndrome
	Primary presenting symptoms
	Predicted or observable side effects
	Anti-neoplastic (anti-cancer attitude)
	Shen/mind/mental
Treatment Goals	Mitigate side effects with zero-toxicity treatment
	Enhance therapeutic effects of chemo and radiation
	improve quality of life and long-term survival
	Assist patients to better tolerate treatment & complete conventional medical treatment
	Restore general health
Modification of integrative care plans	Side effects arise and change
	Disease progresses and creates new symptoms
	Patient progresses through different treatment phases
	modality does not bring about desired outcome, requiring different modality or combination
	Improvement in symptoms requiring less intervention
	Care may shift from patient to family member (s).
syndrome differentiation	Has become an important concept in oncology in China over last decade.
	is reported by type of cancer
	Attempt to understand the molecular basis for each symptom within each cancer to better understand its usefulness in practice
Understanding Cancer in TCM	Stagnation does not always lead to cancer, but it is present in cancer
	TCM attributes emotions as an important internal disease factor
	External causes- lifestyle, exposure, pathogenic factor.
	Qi stagnation- fluid accumulation- Blood stasis- Toxin- Cancer?
Blood stasis	very common in cancer patients with liver, lung, and pancreatic cancers. Stabbing pain of cancer
	Some data suggests increase in metastasis, some not.
Damp Heat	Associated with cancers of the GI tract (Colon, liver, pancreas)
Yin vacuity (fluid deficiency)	Commonly seen in cancers of liver, lung, breast, stomach, and colon
Spleen Vacuity	Extensive research in China looking at this pattern in cancer
	Correlation between spleen vacuity and immunological dysfunction
	Supplementing the spleen is believed to enhance proliferation of splenic cells and
	significantly increase auto-antibody secretory cell number.
	Enhance cytotoxic action of lymphocytes.
Fu Zheng	Huang qi (herb) is the cornerstone of the therapy
	Extensively used as an adjunct to chemotherapy.
	Particularly with non-small cell lung cancer with platinum based therapy.
	Studies suggest that this increased effectiveness of platinum drugs.
	Research suggests longer survival rate.
Zhen Qi Fu zheng Chong Ji	Huang qi- astagalus 20-30g
	Dang shen/codonopsis 20g
	Fu ling/ Poria 10g
	Gou qi zi/Lycium fruit 12g
	Bu gu zhi/Psoralea fruit 10g
	Nu zhen Zi/Ligustrum 12g
	Bai Zhu/ atractylodes  12g
	Zhi gan cao/ honey fried licorice 6g
	Tu si zi/ Cuscuta seeds  12g
Constitutions	Yin vacuity
	Qi vacuity
	yang vacuity
	Blood vacuity
	Blood heat
	Blood dryness
	Binding depression of Liver qi
	Up flaming of liver fire
	Damp heat in LI
	Damp heat in UB
	Stomach Heat.
Considerations	Assessment and interventions based on clinicians experience-results will differ from clinician to clinician= hard to study
	Trend is to combine pattern differentiation and disease diagnosis for future cancer TX
	Have not determined exact relation between patterns and biological processes.

Pain	Subjective component is explicit
	Included the physiologic sensation and an emotional reaction to that sensation.
Classification of pain	Nociceptive- somatic or visceral
	Non-Nociceptive- Neuropathic or psychogenic
	Neuropathic pain- pain from a lesion or disease of the somatosensory nervous system
	Central Neuropathic- central
	Peripheral neuropathic pain- peripheral
Neuropathic pain- positive symptoms	Allodynia- pain due to stimulus that does not normally provoke pain
	Dysesthesia- an unpleasant abnormal sensation, whether spontaneous or provoked.
	Hyperalgesia- increased pain from a stimulus that normally provokes pain.
	Hyperesthesia- increased sensitivity to stimulation, excluding the special senses
	Hyperpathia- syndrome w/abnormal painful reaction to a stimulus, repetitive stimulus, increased threshold.
	Paresthesia- abnormal sensation, whether spontaneous or evoked.
Neuropathic pain- negative response	Analgesia= absence of pain in response to stimulation which would normally be painful.
	Hypoalgesia- diminished pain in response to a normally painful stimulus
	Hypoesthesia- decreased sensitivity to stimulation, including special senses.
	Negative symptoms: weakness, sensory loss, numbness, light tough, position sense, thermal perception, decreased vibration
Neuropathic pain tissue origin	Cerebropathy ex. Brain tumor
	Myelopathy- ex. Spine cord compression
	Radiculopathy- ex. Ependymoma (spinal cord tumor). Dermatome test..
	Plexopathy- pancost tumor in upper lung radiates down arm
	Neuropathy- CIPN (chemo induced neuropathy). Damage/dysfunction of peripheral nerves- motor, sensory and autonomic.
Myotomes	Group of muscles affected by a nerve root.
	Radiculopathy causes: disk herniation, facet arthropathy, central stenosis, spondylolisthesis
neuropathic pain plexus	Cervical- injury, tumor, radiation, Erb’s palsy (c5-C6), Klumpke’s palsy (C8-T1), TOS, Surgery
	Brachial- idiopathic brachial plexopathy, neuralgic amyotrophy, brachial neuropathy, brachial neuritis, shoulder-girdle neuritis, etc.
	Lumbar
	Sacral
Presentation	Chemo: pain, Radiation: paresthesia, weakness
Pain	Chemo: early, severe, Radiation: later in course
Edema	Chemo: Occasional, Radiation: common
Bracial plexus	Chemo: Often lower plexus, Radiation: usually whole plexus
Lumbarsacral	Chemo: Lower, usually unilateral, Radiation: commonly bilateral
Horner syndrome	Chemo: common, Radiation: Unusual
Local tissue necrosis	Chemo: not present, Radiation: common
Rectal Mass (LSP)	Chemo: common, Radiation: not a feature
Myokymia (EMG)	Chemo: usual, Radiation: may be present
Nerve Enhancement (MRI)	Chemo: present, Radiation: usually absent
PET Scan	Chemo: positive, Radiation: usually negative
Neuropathy causes	Idiopathic, Chemotherapy, Infection, Critical Illness, Toxic, metabolic, compression, inherited.
Chemo	Platinum analogues: cisplatin, Carboplatin, Oxaliplatin (affect dorsal root ganglia DNA, sensory neuropathy)
	Taxanes: Paclitaxel, Abraxane, Docetaxel (tubuline inhibitors, affects long nerves)
	Vinca alkaloids: vincristine, vinblastine, vinorelbine, vindesine (affects long nerves)
	other: Bortezomib, Ixabepilone, thalidomide, Lenalidomide. (blood supply issues)
Etiology of neuropathy	Direct effect: nerve infiltration or compression
	Paraneoplastic effect: remote effect of antibody, hormone, protein
	Iatrogenic effect: chemotherapy, radiation, Immunosuppression, Graft vs host disease.
Distribution	Polyneuropathy
	Mononeuropathy
	Mononeuropathy multiplex
	Ganglionopathy
	Small fiber Neuropathy
	Autonomic Neuropathy
Nociceptive pain	pain arising from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.
pathophysiology	activation of nociceptors (A delts or C fibers0 by noxious stimuli that can be mechanical, thermal, or chemical.
	Nociceptors may be sensitized by endogenous chemical stimuli such as serotonin substance P, bradykinin, prostaglandin, histamine.
	Generally described as dull or achy, exacerbated by movement and relieved with rest, localized, and reproducible.
	Nociceptive pain can hurt on touch while neuropathic will not.
examples:	rotator cuff tendonitis, adhesive capsulitis, epicondylitis, De Quervains Tenosynovitis, spinal stenosis, spinal instability, fracture
	arthritis, enthesopathy, GVHD, Scoliosis.
Upper pain disorders in Breast Cancer	neuromuscular: cervical radiculopathy, brachial plexopathy, polyneuropathy, mononeuropathy, post mastectomy pain
	lymphovascular: lymphedema, axillary web syndrome, post thrombotic syndrome
	Musculoskeletal: post surgy pain, rotator cuff disease, bicipital tendonitis, adhesive capsulitis, bony metastases, deQuervains, arthritis
	integumentary- cellulitis, radiation dermatitis
Treatment modalities	Non-pharmacological- exercise, weight loss, PT, Otm lymphedema education
	Pharmalogical- anti-inflammatories, nerve stabilizers, analgesics
	Surgical- laminectomy, injections, nerve block
Pain management	Patient education, weight loss, PT, Ot, assistive devices (cane, neck collar), Orthotics, Modalities
	posture training.
	Pt: Neuromuscular re-education- postural, PNR proprioceptive neuromuscular re-education, core strengthening, scapular retraction,
	Muscle balancing, Soft tisue mobiliztion like Myofacial release, visceral therapy, Craniosacral therpay, MLD
non-pharmacological therapy	heat, cold, electrotherapy, laser, reduce pain, aid wound healing, facilitate tissue compliance, introduce medication, corticosteroid
superfical heat	heat pads, moist compress, hydrocollator packs, paraffin bath, whirlpool bath
	contraindication: acute trauma, bleeding, edema, vascualr disease, large scars, impaired sensation, cognitive deficits.
Deep heating	to muscles, tendons, bones, like ultrasound, mosit heat, laser, TENs, avoid in tumor areas.
Cryotherapy	pain and inflammation musculoskeletal disorders, myofascial pain, spasticity, minor burns.
	contra: cold hypersensitivity, raynaud’s
Pharmacological	opioids (morphine, methadone, oxycodone, NSAID, corticosteroid,
	Nerve stabilizers: anticonvulsants, Tricyclic antidepressants, Serotonin norepinephirine reuptake inhibitors (cymbalta)
	Muscle relaxants,
	injuctions: corticosteroid, Lidocaine, botox
	Topical: capsaicin, lidocaine
	Other: tramadol, NMDA antagonists, clonidine
	Tramadol- weak synthetic analogue of codeine, 1/10 of morphine
	Seratonin norepinephirine reuptake inhibitors (cymbalta)- caution with Tamoxifen. Side effcts: nausea vomit,consipation, dirrhea
	Gabapentin (Neurontin) and Pregabalin (Lyrica)- dizziness, somnolence, weight gain, withdrawl
	Non-specifi NSAIDs: aspirin, ibuprofen, naproxen, diclofenac, celebrex, vioxx. Side effects: Cardio risk, GI risk
Conclusion	Neuropathic, somatic, and mixed pain disorders should be carefully diffferentiated using history, physicla exam, imaging, and
	diagnostic testing where appropriate.
	Treatment modalities should be chosen based on an accurate assessment of the patients pain so as to have
	maximal efficacy while minimizing adverse events.
	multimodal pain management is often needed to achieve optimal outcomes.

Psychiatric and Psychological
Depression in cancer patients	3 to 58%, the majority falls in the 10 to 25%
	Depression if 4x greater in cancer than general population
	More prevalent in advanced cancer like pancreatic 40-50%
	Children with cancer 10-14%
	associated with increase in morbidity and impacts negatively on survival.
Diagnostic assessment	DMS. Gold standard Diagnostic and statistical manual.
	Endicott substitution criteria
	Research diagnostic Criteria
	Structured diagnostic interviews
	Schedule for affective disorders and schizophrenia
	Diagnostic interview schedule
	Structured clinical interview for DSM-III-R
	Screen instruments self-report:
	General health questionnaire
	Hospital anxiety and depression scale
	Beck depression inventory
Depression	Persistent, prominent, dysphoric mood, loss of interest in most activities
	Somatic sx: insomnia, hypersomnia, weight or appetite change, fatigue, psychomotor agitation
	Psychological sx: feeling worthless, suicidal thoughts, memory and concentration difficulties.
Approaches	Inclusive approach- includes that cancer treatment comes with depression symptoms and treat with anti-depressant.
	Exclusive approach- may miss that patient is depressed and not treat them.
	Etiologic Approach- from cancer, illness, or depression.
	Substitutive approach- depressed appearance, social withdrawal, decreased talkative, brooding, self-pity, pessimism.
	Increased Threshold Approach- 7 symptoms
	Brief screening: “have you been depressed most of the time for the past two weeks?” two-item interview, visual analog, Beck inventory
Medical conditions depression	Uncontrolled Pain
	Metabolic abnormalities like Hypercalcemia, sodium or potassium imbalance, Anemia, Def. B12 or folate.
	Endocrinologic Abnormalities: Hyper- Hypothyroidism, Adrenal insufficiency. Low T in men.
	Medications can affect neurotransmitters causing symptoms.
	Steroids, Interferon (renal, melanoma) and interleukin 2, Methyldopa, Reserpine, Barbiturates, Propranolol,
	Chemo agents: Vincristine (All, brain), Vinblastine (breast and Lung cancer), Procarbazine (Brain), L-Asparaginase.
	Corticosteroids in Lymphoma patients, antibiotics (amphotericin B), Tamoxifen (Breast), Cyproterone (Prostate).
Cytokines (pro-inflammatory)	depressed mood, dysphoria, anhedonia, helplessness, fatigue, weight loss, hypersomnia, psychomotor retardation, confusion,
	lack of concentration, anorexia. Cytokines- CNS and the brain affected.
	IL-1, IL-6, TNF-alpha cytokines. Anti-depressants can help.
Depression other:	Depression and hastened death (like AIDS patients) with anti-depressant the desire to die decreased.
	Tricyclic antidepressants low dose 25-125. Duloxetine was found to be very effective.
	Antidepressants that can affect Tamoxifen chemo: Venlafaxine, Mirtazapine, Bupropion, Escitalopram.
Psychostimulants	Quicker acting anti-depressants: dextroamphetamine, methylphenidate, modafinil, Pemoline (removed due to liver toxicity)
	Mood, energy, cognition, improved. Fatigue and appetite improved.
Delirium in Cancer patients	15-305 in hospitalized patients, 40-80% in advanced disease, palliative care.
	Harm to self, family, staff, mortality. Interferes with symptom assessment and control.
	Untreated can result in dementia or cognitive disorders
	pathophysiology of delirium- supports the role of psychopharmacologic management, dopamine blockers.
assessment	DSM
	Delerium symptom interview
	Confusion Assessment method
	Delerium rating scale, confusion rating scale, memorial delirium assessment scale
	cognitive impairment screening scale: mini-mental state exam, Short portable mental status Questionnaire, cognitive capacity screening
Criteria	Disturbance of consciousness, awareness of environment, reduced focus, shifting attention.
	change in cognition- memory deficit, disorientation, language disturbance, perceptual disturbance.
	Evolve over a short period of time, fluctuate throughout the day. Medical condition etiologically related to disturbance.
	Delirium is a disturbance of arousal and cognition. Subtypes: hyperactive (24%), hypoactive, mixed (36%).
	Hypoactive delirium is under diagnosed. These patients are quiet, appear depressed, and less distress and delusions. 48%
	Tx: antipsychotics. Prevent and reverse etiology, control symptomatology.
Delirium in advanced cancer	Direct: primary brain tumor, metastatic spread
	Indirect: hypoxia, Metabolic encephalopathy, electrolyte imbalance, withdrawal states.
other causes:	Chemo agents, steroids, radiation, opioids, anticholinergics, antiemetics, infection,
	Hematologic abnormalities, nutritional deficiencies, paraneoplastic syndromes.
non-pharmacological therapy	Minimize use of catheters, IV lines, physical restraint, monitor for dehydration and electrolyte, nutrition, control pain
	Minimize medications, sleep hygiene, re-orient frequently.
	Pharmacological prevention of delirium has mixed results, they do not prevent delirium in palliative care setting.
	Dexmedetomidine use as anesthetic may lower post-op delirium significantly.
	Haloperidol < 4.5 mg and  (atypical antipsychotics like olanzapine and Risperdal) are effective in managing symptoms.
	Risk of stroke, death using these drugs.

Palliative Care for pain and symptoms	specialized medical care for people living with serious illnesses. It focuses on providing relief from the symptoms
	and stress of serious illness. It is appropriate at any age and stage of a serious illness and provided along with curative treatment.
palliative is	Evidence based medicine (EBM), provided alongside efforts to cure an illness, good at pain and symptom management
	through the illness, patients and family centered, focuses on quality of life as defined by the patient and family unit.
Palliative care is not	giving up on a patient, in place of curative or life-prolonging care, limited to specialists, same as hospice.
Hospice	compassionate care at the end of life, team-oriented to expert medical care and pain managment, emotional and spiritual support.
	Provided in a variety of settings including home, resident facility, hospitals, etc.
	Medicare hospice benefits is provided to those who have been medically certified as terminally ill with a prognosis <6 months to live.
Old model	diagnosis- disease modifying treatment- terminal phase of illness-palliative care- hospice.
current care continuum	diagnosis- disease modifying treatments-palliative care- terminal phase of illness-. Hospice- death-bereavement.
	QOL – quality of life, EOL- end of life
Importance of Palliative Care:	goals and needs change. Patients go through many stages of illness, personhood, life relationships, perspectives, QOL
	better outcomes for patients, family, providers: focus on symptoms and pains through treatments not just EOL.
	Explore worries, fears, hope throughout the treatment.
	assess patient and family needs
	improve our communication on multiple levels.
Healthcare utilization
Life expectancy	1900- 47yo. 2000- 75yo.
Usual place of death	1900- Home, 2000- Hospital.
Reason for Death	1900- Infectious disease, communicable disease. 2000- Chronic illness.
Most medical Expense	1900- Paid by family, 2000- paid by Medicare.
Disability before Death	1900- Not common, 2000- average of 2 years.
Integration of Palliative Care	study found palliative care has meaningful improvements in QOL and mood, patient was less depressed, the patient received less
	aggressive care as they got sicker, increased advance directives and DNR wishes documented, average life
	expectancy was ~3 months longer than those who received usual oncological care alone.
Palliative Care Team	Doctors, nurses, specialists working with other doctors to provide an extra layer of support.
	MD’s, Nurse practitioners, Office practice nurses, social workers, pharmacists,
	Chaplain, Integrative practitioner, Medical and Nurse fellows.
Reason to consult	pain and symptom management
	complex psychosocial/spirit support required
	assistance in clarifying goals of care
	assistance in withdrawal of life sustaining treatment
	Actively dying patient requires specialist input
	complex disposition planning.
Palliative Care assessment	Review clinical course
	Focused assessment of chief complaint
	Disease understanding
	dignity therapy question
	Brief symptom assessment scale
	Detailed social history
	Spiritual assessment
	patient and family goals of care
	Pharmacologic and non-pharmacologic care, holistic treatment
Cancer Symptoms	Pain, vomit, nausea, fatigue, Insomnia, Anorexia, Dyspnea, anxiety, depression, distress.
complementary and integrative therapy	reduced therapy related toxicity, improvement in disease-related symptoms, improve QOL
pain management	Pain is an unpleasant sensation and emotional experience associated with actual or potential tissue damage.
	whatever a person experiencing it says it is. Exisiting where the person says it does.
	Physiologic sensation and emotional reaction to that sensation= total pain.
Cancer and pain	cancer patients experience pain throught treatment
	1/3 actively receiving cancer treatment
	2/3 of persons with advanced malignancy
	3/4 of persons with advanced cancer admitted to the hospital experience pain on admission
	54% of patients near the end of life.
Causes	60-65% tumor invasion in metastatic disease
	20-25% treatment related pain to surgery, chemo and radiation
	10-15% chronic conditions
pain vs suffering at end of life	Existential distress, uncertainty of illness, loss of control
	dimensions of QOL, requires interdisciplinary assessment and management.
Guidelines of pain management	Interdisciplinary approach, cultural considerations, assessment should be regular and on-going,
	for controlled substances implement a risk management plan, document response, educate family,
	identify and address barriers, address suffering, refer to providers with specialized skill.
Assessment of pain (OLDCART)	Onset, Location, duration, characteristics, aggravating factors, Relieving factors, therapies tried
	patient description of pain
	meaning of pain
	how pain impacts quality of life (QOL)
	Cultural considerations
	Goals of care
	medication use history: current, past, what worked, what didn’t?
	psychosocial history: family friend support, substance use history?
Pharmacological mgmt of pain	Non-opioids: acetaminophen, analgesic/antipyretic, NSAID- antipyretic, anti-inflammatory, analgesic. Adverse effects.
	Opioids- morphine, oxycodone, oxymorphone, fentanyl, hydromorphone, metadone.
	less common- Buprenorphine, codeine, hydrocodone, tapentadol, tramadol. Adverse: respiratory depression, constipation, sedation.
	Adjuvants analgesics: anticonvulsants for neuropathic nerve pain: gabapentin and pregabalin
	anti-depressants: tricyclic serotonin-norepinephrine reuptake inhibitors (SNRIs)
	local analgesics- topical, intravenous, spinal.
	Corticosteroids- activates/increase appetite, side effect with prolonged use.
Routes	oral, transmucosal, rectal, transdermal, topical, parenteral, spinal.
Interventional therapies	neurolytic blocks
	neuroblative procedures
	vertebroplasty/kyphoplasty
	epidural steroid injection
	Intrathecal pump
Non-pharmacologic strategies	Physical: rehab medicine, exercise, cold/heat, self-care, walking.
	Psychosocial: CBT, psychotherapy, relaxation, meditation, hypnosis, music therapy
	Complementary/Integrative: systemic desensitization. Acupuncture/acupressure, Yoga, Tai Chi, massage, Reiki, Qigong.
Conclusion	Palliative care focuses on providing relief from the symptoms and stress of serious illness at any stage.
	It is not the same as Hospice care. The approach to pain is interdisciplinary.
	Acupuncturists play a vital role in symptom management and support. Pain relief is necessary and highly achievable.
Acupuncture mechanisms of Action	Biomed mechanism of actions for acupuncture
	Fascia and connective tissue
	Neurotransmitters and the autonomic nervous system
	Neuro-imaging studies
	Conveying the information to other health care professionals.
Objectives	List neurotransmitters involved in analgesic effect of acupuncture
	Describe evidence of modulation of ANS by acupuncture
	Summarize finding in neuro-imaging of acupuncture
	Explain the current evidence of mechanisms of action for acupuncture to health care professionals.
Acupuncture Consensus	Acupuncture is becoming more accepted n an Oncology setting for pain and symptom management
	Data shows measurable neurological effects
	Clearly communicating mechanisms of action to the medical team will improve understanding and benefit patient care.
Acupuncture points and myofascia	location of acu points and meridians in a serial gross anatomical sections through a human arm.
	Ultrasound and de qi- twisting cause changes in collagen fibers. Nervous sensors on myofascial planes, cause downstream events.
How it works?	TCM- theraputic effect results from manipulation of flow of qi in meridian. This is too unfamiliar with western health care pros.
	Neuroscience research helps with neuroanatomy and physicology to help explain to western health care professionals.
Endogenous Opioids	Acupuncture helps stimulate the discharge of endogenous (internally sourced) opioids- substances that suppress pain.
	This discovery initiated a scientific and evidence based explanation for the mechanism of acupuncture.
	Stimulation of the acupoint by a needle sets off a nerve signal to the brain to release endorphins,
	acupuncture may activate additional neural pathways and neurotransmitters.
	Endomorphin-1, beta endorphin, enkephalin, and serotonin levels in plasma and brain tissue.
Analgesia by acupuncture	Is blocked by opioid receptors blockers. Tolerance to pain.
	E-acupuncture: analgesia Yes
	E-acupuncture and Saline: analgesia Yes
	E-acupuncture and naloxone: analgesia No
	Sham E-acupuncture at non-acupoint: analgesia No
	Saline alone: analgesia No
	Naloxone alone: analgesia No
	No treatment: analgesia No
Different receptors at diff locations	2 hz and 15 hz: two opioid receptors
	100 Hz: another different opioid receptor
local injection of antibodies or chemical	2 hz- neurotransmitter B-endorphins location in midbrain
(old study)	2 hz- Enkephalins in the spinal cord
	100 Hz- Dynorphins in the spinal cord
New study- Adenosine	Adenosine peaking up to 200 microdialysate(nm) in 30 minutes
	AMP peaking up to 400 in 30 minutes.
Pain pathway:	trauma to skin- peripheral nociceptors engage- local anesthestics and anti-inflammatory drugs
	local anesthetics to peripheral n.
	dorsal ganglion root- to the dorsal horn (local anestheris, opioids, alpha2agonists) of spinal cord- up spinothalamix tract to brain.
	pain- perceived by brain (opioids, Alpha2agonists)- descending modulation back to dorsal horn.
	Acupuncture gives additional signs around this pathway, suppress the conduction of pain signals up to the brain.
Yin and yang: autonomic N. system	Sympathetic is like Yang: hot, breathing changes, dilation, excitement, fight and flight.
	Parasympathetic is like Yin: quiet, relaxing, HT rate down, digest and rest.
	LI4 regulates Sympathetic N.S. 2 hz and 20 hz. , low frequency increases parasymathetic, tonic. 20 hz phasic- comes and goes.
	St36 on digestion: digestive tract movement, 10 min. e-stim promoted the GI tract to move for up to 2 hours.
Hypertension and BP	e-stim inhibition of cardiovascular sympathetic neurons that have been activated through visceral reflex stimulation.
	this is mediated through activation of neurons in the arcute necleus of the hypothalamus, vLPAG in the midbrain, and NRP in medulla.
	Glutamate, acetylcholine, opioids, GABA, nociceptin, serotonin, and endo-cannabinoids all appear to participate in the E-stim
	hypotensive respnse although their importance vararies between nuclei.
Acupuncture and neuroimaging studies	MRI- activation and deactivation of cortical regions using LI2. Saliva production also increased.
	theory- stimulated the parasympathetic ns to produce more saliva.
	parts of brain light in in MRI with acupuncture. Body and somatic signals.
Acupuncture and Limbic system	Limbic is part of regulation of moods, emotions like fear, anger, anxiety.
	responder’s vs non-responders when getting acupuncture. Some people do not seem to respond to acupuncture.
Summary	Still much is unknown how acupuncture works, strong evidence is coming from neuroscience.
	Clinically it is found acupuncture can modulate the nervous system at the molecular level (neurotransmitters), and matrix
	level like activating or deactivating certain neural circuits.

Acupuncture mechanisms of Action	Biomed mechanism of actions for acupuncture
	Fascia and connective tissue
	Neurotransmitters and the autonomic nervous system
	Neuro-imaging studies
	Conveying the information to other health care professionals.
Objectives	List neurotransmitters involved in analgesic effect of acupuncture
	Describe evidence of modulation of ANS by acupuncture
	Summarize finding in neuro-imaging of acupuncture
	Explain the current evidence of mechanisms of action for acupuncture to health care professionals.
Acupuncture Consensus	Acupuncture is becoming more accepted n an Oncology setting for pain and symptom management
	Data shows measurable neurological effects
	Clearly communicating mechanisms of action to the medical team will improve understanding and benefit patient care.
Acupuncture points and myofascia	location of acu points and meridians in a serial gross anatomical sections through a human arm.
	Ultrasound and de qi- twisting cause changes in collagen fibers. Nervous sensors on myofascial planes, cause downstream events.
How it works?	TCM- theraputic effect results from manipulation of flow of qi in meridian. This is too unfamiliar with western health care pros.
	Neuroscience research helps with neuroanatomy and physicology to help explain to western health care professionals.
Endogenous Opioids	Acupuncture helps stimulate the discharge of endogenous (internally sourced) opioids- substances that suppress pain.
	This discovery initiated a scientific and evidence based explanation for the mechanism of acupuncture.
	Stimulation of the acupoint by a needle sets off a nerve signal to the brain to release endorphins,
	acupuncture may activate additional neural pathways and neurotransmitters.
	Endomorphin-1, beta endorphin, enkephalin, and serotonin levels in plasma and brain tissue.
Analgesia by acupuncture	Is blocked by opioid receptors blockers. Tolerance to pain.
	E-acupuncture: analgesia Yes
	E-acupuncture and Saline: analgesia Yes
	E-acupuncture and naloxone: analgesia No
	Sham E-acupuncture at non-acupoint: analgesia No
	Saline alone: analgesia No
	Naloxone alone: analgesia No
	No treatment: analgesia No
Different receptors at diff locations	2 hz and 15 hz: two opioid receptors
	100 Hz: another different opioid receptor
local injection of antibodies or chemical	2 hz- neurotransmitter B-endorphins location in midbrain
(old study)	2 hz- Enkephalins in the spinal cord
	100 Hz- Dynorphins in the spinal cord
New study- Adenosine	Adenosine peaking up to 200 microdialysate(nm) in 30 minutes
	AMP peaking up to 400 in 30 minutes.
Pain pathway:	trauma to skin- peripheral nociceptors engage- local anesthestics and anti-inflammatory drugs
	local anesthetics to peripheral n.
	dorsal ganglion root- to the dorsal horn (local anestheris, opioids, alpha2agonists) of spinal cord- up spinothalamix tract to brain.
	pain- perceived by brain (opioids, Alpha2agonists)- descending modulation back to dorsal horn.
	Acupuncture gives additional signs around this pathway, suppress the conduction of pain signals up to the brain.
Yin and yang: autonomic N. system	Sympathetic is like Yang: hot, breathing changes, dilation, excitement, fight and flight.
	Parasympathetic is like Yin: quiet, relaxing, HT rate down, digest and rest.
	LI4 regulates Sympathetic N.S. 2 hz and 20 hz. , low frequency increases parasymathetic, tonic. 20 hz phasic- comes and goes.
	St36 on digestion: digestive tract movement, 10 min. e-stim promoted the GI tract to move for up to 2 hours.
Hypertension and BP	e-stim inhibition of cardiovascular sympathetic neurons that have been activated through visceral reflex stimulation.
	this is mediated through activation of neurons in the arcute necleus of the hypothalamus, vLPAG in the midbrain, and NRP in medulla.
	Glutamate, acetylcholine, opioids, GABA, nociceptin, serotonin, and endo-cannabinoids all appear to participate in the E-stim
	hypotensive respnse although their importance vararies between nuclei.
Acupuncture and neuroimaging studies	MRI- activation and deactivation of cortical regions using LI2. Saliva production also increased.
	theory- stimulated the parasympathetic ns to produce more saliva.
	parts of brain light in in MRI with acupuncture. Body and somatic signals.
Acupuncture and Limbic system	Limbic is part of regulation of moods, emotions like fear, anger, anxiety.
	responder’s vs non-responders when getting acupuncture. Some people do not seem to respond to acupuncture.
Summary	Still much is unknown how acupuncture works, strong evidence is coming from neuroscience.
	Clinically it is found acupuncture can modulate the nervous system at the molecular level (neurotransmitters), and matrix
	level like activating or deactivating certain neural circuits.

Acupuncture for cancer pain	Science and Cancer pain, evidence on Oncology acupuncture for pain, research on oncology acupuncture for pain.
	53% of all cancer patients will have pain, 33% cancer surviors after cureative treatment, 59% patients undergoing cancer treatment, and
	64% in advanced metastatic or terminal cancer.- van den Beuken Everdingen et al. (Prevelence of cancer pain)
Cancer is complex	through all stages: active tx, palliative care, survior-ship.
	mult-factored: disease, psycho-social, treatment.
	Treatment: surgery, chemo, radiation, Targeted Tx, hormonal tx, Immune tx.
	Nociceptive pain: 1) somatic like arthritis pain, 2) visceral like ascities causing abdominal pain
	Neuropathic pain: ex. Neuropathy (from chemo)
Common pain medications:	Opioids (long: Oxycontin, fentanyl patch | Short: Percocet, Dilaudid)
	Anticonvulsants (Gabapentin, Pregablin),
	Antidepressants (Duloxetine),
	NSAIDS (Motrin, Naproxen) from mild muscular skeletal
	Acetaminophen.(prolonged use can cause liver damage.
Mechanisms of Acupuncture	Stimulation of acupuncture sites releases endogenous opioids in brain.
	Opioid antagonists block analgesic effects of acupuncture
electric acupunctre/e-stim/EA:	2 Hz: b-endorphins, endomorphin, enkephalin, targeting new and delta receptors.Brain releases these.
	100 Hz: dynorphin, targeting k receptor. Spine releases these.
	fMRI brain scans: meta analysis 779 papers identified. 34 eligible for meta-analysis.
	Brain response to acupuncture stimuli encompasses a broad network of regions consistent with not just somatosensory, but also
	affective and congnitive processing. While results are heterogeneous, from a descriptive perspective most studies suggest that
	acupuncture can modulate the activity within specific brain areas, and the evidence based on meta-analysis confirms some of
	these results. More higher quality studies with more transparent methodology are needed to improve the consistency
	amoung different studies.
	Limbic system- congnition and emotion. Psychological aspects of pain both acute and chronic.
	Randomized Controlled Trials (RCT) review 15 RCTs. Acupuncture was not better than drug Tx (n=886, RR: 1.12, P= .09)
	However combination of drug treatment and acupuncture was significantly better (n=437, RR: 1.36, P= .003).
	Limitations: high risk of bias, substantial methodological limitations.
	Conclusion: could not be drawn, future rigourous RCTs necessary to assess clinical efficacy of AC for cancer pain.
Interventions	pts educated on joint pain, told to stay active and continue with usual medical care.
	electro-acupuncture: 2x week for 2 weeks and 6 weekly after. Manualized protocol “Bi syndrome” patients,
	add points for constitution, fatigue, anxiety. 2 Hz at  points localized joint pain.
	primary- joint pain, brief pain inventory (BPI)
	secondary- fatigue, sleep, anxiety, depression
	30% in pain reduction with electro acupuncture vs Sham acupuncture in baseline expectancy.
	Responders vs non-responders to acupuncture exist. People who believe acupuncture works, even sham acupuncture worked on them.
	Mind-Body effects of acupuncture: a patient feels some relief and begins to feel acupuncture is working.
	Sham acupuncture- you expect it to work and so it does (top down approach).
	high expectation patient need light treatment, low expectation patients needs E-stim acupuncture.
Process acupuncture: art and science	50%: 1) diagnosis, 2) patient care, 3) patient rest 4) psycho-social support.
	50%: the treatment using needles, tui-na, Moxa, guasha, herbs, etc.
	note: Acupuncture can produce analgesia (loss of pain sensation) , but effects of acupuncture were blocked by opioid antagonists.
Oncology acupuncture:CINV	Most common symptom, more common in chemo than radiation. Acute, delayed (after chemo), anticipatory (psychological).
	some can be medical emergencies.
Medical emergencies	Increased intercranial pressure: brain mets/swelling/bleeding. Headache with projectile vomiting.
	Seen in brain tumor or cancer that spreads to brain like lung, breast, melanoma, etc.
	Bowel obstruction: from inside (stomach/colon/rectal cancer) or outside (GYN/peritoneal/sarcoma) obsturction
	usually has abdomnal bloating/pain and reduced bowle movement
	Systemic illness (serious infection, heart attack, metabolic disorders, etc.)
emetogenic chemo drugs	High: cisplatin, cyclophosphamide, dacarbazine, combo of drugs
	Moderate: Bendamustine, Carbo/Oxali-platin, cyclophosphamide, cytarabine, Dauno/epi/doxo-rubicin, Ifosfamide, Irinotecan.
	Low/Minimal: wide list, but not a severe as above.
Acute emesis meds	One, two or three:
	5-HT3 receptor antagonists: Ondasetron (zofran), palonosetron (Aloxi), side: constipation/headache
	Neurokinin-1 receptor antagonists: aprepitant (emend), Rolapitant (Varubi), side: fatigue, hiccup
	Glucocorticoids: dexamethosone (decadron), side: insomnia, hyperglycemia
Acupuncture	Established cause and primary doctor is aware of.
	If significant and worsening, communicate with primary doctor.
other situation	Delayed from chemo: Olazapine or metoclopramide
	Anticipatory- relaxation, hypnosis, ginger, lorazepam (Ativan)
	Difficult to control- consider cannabinoids/medical marijuana.
Patient assessment	Anti-nausea meds not working well, minimal relief, wants less meds, acupuncture for other things as well as nausea.
	Chemo schedule, onset of symptoms, corticosteroids may delay symptoms, check labs: contraindicatins: ANC < 0.5 , platelets < 20k.
Treatment planning	Prior to chemo, when symptoms appear, sever: 2x per week, during episode 10 hz, 25 minutes.
	special considerations: difficulty lying prone or supine, enusre they can reach you/call button, have bucket close.
	Tx strategy: chemo/radiation is a toxic heat, principle: clear heat, harmonzie center, fortify ST/SP.
Common patterns	SP damp (bloating, swelling, const./diarrhea), ST heat (reflux, red), KD vacuity (wasting, diarrhea, SOB)
Point Prescription	Pc6, LI11, ST36. SP damp: pc6, ren12, st36, Sp9, ST heat: PC6, Li11, St25, St44, KD vacuity: PC6, ST36, KD3, Du20
	acute episode: pc6, st36, in between episode- support ST/SP, clear heat, harmonize center.moxa/TDP.
Additional Tools	teach acupressure PC6, seasickness bands, ear seeds (shenmen), mind-body imagery/meditatin, ginger, peppermint, moderate exercise.

Chemo induced Peripheral neuropathy	(CIPN)
	CIPN common adverse effect from certain treatments: Taxanes, platinum, vinca alkaloids, bortezomib, and thalidomide
	sx: pain, numbness, tingling, weakness, autonomic neuropathy (incontinence, bowel movement).
	Long-term effects on quality of life and can continue for years.
	Taxanes- breast and ovarian cancer patients. Axonal microtubule structure disruption.
	Platinums- colo-rectal, sometimes ovarian patients. Dorsal root ganglia damage, mitochondrial dysfunction, neural apoptosis,
	either by DNA crosslinking or oxidative stress.
	Vinca alkaloids- liquid tumors like lymphoma. Alterations in neuronal cytoskeleton causing axonal degeneration.
	Bortezomib-multiple myeloma
	Thalidomide- multiple myeloma
	48% of cancer patients have CIPN, 61% in first month of chemo, 30% after 6 months of completing chemo.
Unpredictable course	many improve, or persist, or worse over time du to permanent damage to nerves.
	6 years symptoms can persist for breast and colon cancer patients.
risk factors	Baseline neuropathy, diabetes, Smoking, decreased creatine clearing, pharmocogenomics.
Assessment CIPN	Objective: Neurological, vibration sensation test, nerve conduction
	Subjective: NCI-CTCAE, patient reported outcomes, composite scales: TNS
	Reduction of chemo may be done to help with CIPN.
	RCT: E-stim acupuncture actually made CIPN worse and Sham Acu was better result.
Nervous system disorder
Peripheral motor neuropathy	grade 1: asymptomatic, clinic or diagnostic observation only, intervention not indicated
	grade 2: moderate symptoms, limiting instrumental ADL
	grade 3: Severe symptoms, limiting self care ADL, assistive device indicated.
	grade 4: Life threating consequences, urgent intervention indicated
	grade 5: death
Peripheral sensory neuropathy	grade 1: Asymptomatic, loss of deep tendon reflexes or paresthesia
	grade 2: Moderate symptoms, limiting instrumental ADL.
	grade 3: Severe symptoms, limiting self care ADL
	grade 4: Life threating consequences, urgent intervention indicated
	grade 5: death
positive trial: Duloxetine
	There are studies that show acupuncture may be effective in persistent CIPN, however is not a cure for nerve conduction damage.
CIPN presentations	tingling, numbness, burning sensation, pain, cramping, muscle weakness, sensitive to heat or cold or touch
	balance issues, altered gait.
	may develop weeks or months after chemo, starting in fingers and toes then progress towards the body
	CIPN may result in limiting, delaying, or discontinuing chemo. Gabapentin and pregabalin may be used in treatment, not a cure.
Acupuncture	increase blood flow to limbs, improver sensory/motor n. conduction, accelerating nerve repair, decrease neuropathic pain
	early intervention and frequency treatments may increase efficacy.
	Caution: lymphedema or local infection.
Patterns CIPN	toxins invading channels, qi and blood stagnation, qi and blood deficiency, Internal wind, Damp accumulation.
	acu: Li4, Li11, TB5, ST36, GB34, Liv3, Bafeng (feet), and Baxie (hands)
	sp6 and liv8 for blood deficiency
	sp9/st40 for phelgm
	Li11 and Liv2- clear heat
	retain needles 30 min. 2-5 hz , pulsing sensation, pacemaker (estim contraindicated)
	1x for 10 weeks. Severe” 2x a week.
	Other: massage therapy, reflexology, physical therapy, exercise
	Acupuncture is helpful in reducing CIPN symptoms.
Cancer Related Fatigue (CRF)	CRF- distressing, persistent, subjective, physical, emotional, cognitive tiredness, exhaustion, interferes with usual functioning.
Epidmiology	between 9-90% prevalence according to diagnostic criteria.
	1/3 to 1/4 will have fatigue beyond treatment
	High during chemo and radiation, in advanced disease and bone metastasis.
Consider contributory factors:	sleep quality, metabolism, emotional health/mood disorders, medication adverse effect
	Cardiovascular/Respiratory/oxygen, pain
	Anemia, CHF, hypo/hyper thyroid, medications, depression.
CRF	Low clinical priority, no definitive diagnostic work up, no definitive treatment, patient feels dismissed.
	There are proven behavioral and non-pharmacologic interventions
ICD-10	Sx present every day during 2-week period in the past month.
	significant fatigue, diminished energy, increased need to rest, disproportionate to recent change in activity.
	5 of these: general weakness, limb heaviness
	diminished concentration or attention, decreased motivation,
	insomnia, hypersomnia,
	sleep unrefreshing, struggle to overcome inactivity
	emotional to feeling fatigue
	Difficulty to completing daily tasks, short term memory issues, fatigue lasting hours.
Measure of Fatigue	0-10, 0-3 none/mild, 4-6 moderate, 7-10 severe.
	Timing and impairment.
General strategie for fatigue	self-monitor fatigue levels, prioritize energy conservation, pace, delegate, schedule activities
	use labor saving devices, postpone nonessential activities, limit naps, structure daily activity, one activity at a time
	find meaning in current situation,
Nonpharmacy:	exercise program based on limitations (degree of stage of cancer), walk, job, swim, yoga, tai chi, massage, CBT,
	nutritional support , CBT for sleep, sleep hygiene. MBSR and acupuncture.
Fatigue during active treatment	cyclical and self-limiting, delayed onset of symptoms, symptoms may resolve during the intervals
	Mild and moderate fatigue may still be active in chemo intervals. Deficiency signs: pulses, voice, gait.
	Cumulative effect of chemo: fatigue last longer, pulses less forceful.
Acu/TCM principle	Invigorate- use draining points not tonify. 30 min.
	Rx: Li11, Li4, SP9, Liv2, Du20, Kd1
	One day prior to Chemo, 1-2 x per week.
	Incorporate exercise, get massage.
post chemo chronic fatigue	Kd jing/Qi def., “lacking a second wind”, constitution state of low energy, cold signs, desire warm.
	Tonfiying, gentle treatment: big points (ST36, Sp6, Li10), few needles, 30 min. , 1-2 per week
	TDP lamp, Qigong, Nutrition.
	Heat toxicity- li4, li11, st44, liv2, st36, pc6
	Liver qi stag,: Gb34, Liv3, Li4, St25
	Phelgm obstruction: TB5, ST40, SP9
	Spleen Qi Def: Ren6, Ren12, Sp6, BL20, 21
	Heat Blood def.: HT6, SP6, BL17
	KD Qi Def.: Ren 6, SP6, KD3, Du20
Hot Flashes	Sudden feeling of warmth, usually intense over face, neck, and chest. Skin may redden like blushing.
	Profuse sweating can occur and patient can feel chilled.
Pathophysiology	Mechanism not fully understood. Multiple complex hormonal reactions
	Estrogen, norepinephrine, and serotonin release.
	dysfunction of thermoregulatory center caused by changes in estrogen levels. Vasomotor.
causes	Premature menopause, chemotherapy, Oophorectomy. Men: prostate CA on androgen deprivation tx.
	Systemic antiestrogen TX for hormone-receptor Br Ca. (Tamoxifen)
Hot flash in cancer	70%. Common, persisting, worse sleep, more fatigue, poor QOL.
	Tx: estrogen based therapies, but contraindicated in Cancer.
	Venlafaxine(75mg), Citalopram (10mg), paroxetine, gabapentin (900mg), pregabalin, clonidine.
	RTC: electro-acupuncture was beneficial in treating hot flash.
Decision to use acupuncture	sociodemographic- clinical – cultural
	attitude- perceived effectiveness of acupuncture
	subjective norms- decision support from family and doctors
	behavioral control- practical concerns related to using acupuncture.
	Preference for natural therapies and symptom appraisal leads to decision to use acupuncture.
	Patients claim tey just do not want to take any more pills and choose acupuncture.
Oncology acupuncture: HF	Norepinehprine thought to be primary neurotransmitter responsible for lowering the thermoregulatory set point.
	Triggers the heat loss mechanism (perspiration, vasodilation)
	norepinehprine production and release thought to be inhibited by endorphins
	Acupuncture release of endorphins and there inhibit norepinehprine.
Thermoregulatory temperature
dysfunction in hot flashes	1.  core body temperature threshold/baseline changes
	2. brain – neurochemical imbalance
	3. peripheral vasculature- changes in vascular reactivity.
Patient experience	QOL, Sleep, Anxiety, Social interactions (we want to know these, if HF affecting this)
Assessment	Frequency of HF?
	Intensity of HF?
	Duration of HF?
	Time of Day or night?
	Night sweats?
	Men: Degarelix (Firmagon) GnRH inhibitor. Gonoadotraphin releasing hormone antagonist. Prevents prod of testosterone.
	Leuprolide (Lupron Depot) Lutenzing hormone-releasing hormone agonist, prevent prod of testosterone.
TCM patterns	Kidney Yin vacuity
	Kidney yang vacuity
	Dual vacuity of Kidney yin and Yang
	Toxins invading channels.
treatment planning	Start: 2x a week followed by weekly.
	Needle retention 30 min.
	10 treatments in initial course.
points:	L11, Kd3, Kd6, Sp6, Liv2, Liv3, Ren 4, Ren6, Du 20,
	Erjian: heat clearing auricular apex ear, ear seeds.
	E-stim: ST36 and sp6. SP6 and Liv3. (increase the release of beta endorphin activity). 2Hz
Lifestyle: avoid/limit intake	Alcohol, caffeine, nicotine
	hot and spicy foods, hot beverages, excess sugar.
	maintain healthy weight, overweight increases HF
	Exercise regularly, in a cool environment, avoid exercise before bed
	dressing in layers: patient can remove layers as needed.

Provider- Patient communication	Emotional: life perspective changes, fear of recurrence and mortality, hardship in future planning
	identity shifts, societal and cultural expectations
	Physical-psychological: body image adjustments, scars, permanet changes due to surgeries, sexuality/intimacy,
	Fertility, reconnecting with body post-treatment.
Pediatric	Parents play a key role in child’s medical care and treatment plan
	Important to establish and engage in relationship with parents and caregivers.
	Appropriate playful interactions are helpful when treating children.
Young adult	Life interrupted during prime self development
	unique levels of isolation felt through treatment experience
	Strong desire to complete life cycle development tasts prior to death, aides in more intense goals for survival
	potential to be withdrawn and disengaged with providers, family, friends.
Older adults	potiential for minial caregivers to assist with physical needs and advocacy
	with more time to establish themselves, difficulty letting go to independence.
Family	Emotionally tied unit. Biological and close friends.
	Family illness: illness, disability, death are universal experiences in families.
	Family concerns should be understood and addressed.
	Assessment and management of distrss in families at end of life is vital, family relationships can predict individual distress at the end.
	Consider multipe perpectives and narratives.
Partners	Sexual intimacy, fertility concerns, grieving multiple losses as a couple, facing new normal together, future uncertainies.
Parents	Child’s health after treatment, anxiety about recuurence and life never being the same.
Siblings	Being the healthy one, being the sick one, each feeling guility.
Children	will parents be ok? Are they going to leave me? Will they die? Can they give attention?
Friends	expect you to return to normal activities, worries you wont relate the same way,
	feeling differrent than peers, expect you are over cancer.
Patient culture/values/beliefs	Let them tell you who they are, what is important, what they believe
	Be aware of your own assumptions, biases, how and what they communicate, what medical chart says of prognosis.
Phase 1: initial diagnosis	patient will be overwhelmed, destablized until treatment plan is in place.
	Clinician role- manage anxiety and fear.
	communication strategy: establish rapport, build theraputic alliance. When patient trusts they will reach out.
Phase 2: during treatment	May start to feel physical symptoms and side-effects.
	Patient feels more focused on goals to complete treatment
	Strrategy- do not focus on prognosis, but on treating rthe physical and emotional symptoms.
Phase 3- post treatment	Most patients are excited to not do multiple medical appointments.
	They want to move beyond the cancer, some still feel emotional impact, anxiety and sadness can settle in.
	Some face long-term side-effects.
	Strategy- acknowledge their feelings, normalize their fears, introduce new rapport and ways to keep relationship going.
	Try to to dis-regard their needs because they are cancer free.
Phase 4: recurrence	Emotion can hit harder, more fragility in mood. Physical symptoms increase.
	Balancing of patients wishes to talk about fears, death, and remaining hopeful surface.
	Strategy: do not be afraid to talk about fears, remain curious how they perceive recurrence, let them guide the talk.
Phase 5: end of life	Some patients struggle to accept prognosis
	Some can acknowledge their death and wish to engage in life reviews, legacy discussion.
	Help them stay relaxed as possible to alleviate suffering physically.
	Strategy: be present, emphaty, be silent, hold the space for these patients.
	Stay in the “here and now” focus on the moments. Gain better self-awareness of your own death and anxiety,
	how that impacts your communication with patients end of life.
Difficult patient or caregiver	Acknowledge their frustration, contain the situation as best as possible.
	Wrap up treatment if behavior escalates.
	Don’t hesitate to speak to the unacceptable nature of any aggression towards you.
	Seek supervisory assistance when necessary.
	Try to remember that their emotions are often a displacement of worry for themselves or loved ones.
Family / friends during treatment	Look at medical chart, ask patient if they want to share medical chart if family/friends asks quesitons, otherwise no.
	Inform medical team if you cannot respond.
	As a provider you play an important role in alievating both physical and emotional symptoms.
Talking about Integrative medicine	patients will ask about many types of therapies they hear about on internet.
	Patients want to explore all options for a disease with poor prognosis
	Usually dissatisfaction with current available treatment.
	Patient empowerment.
when talking with patients	maintain open mind and empathetic attitude. Listen. Look for deeper issues.
	figure out what the patient really needs. Formulate a plan that is evidence based and tailored to their needs and preference.
	Use the opportunity for a comprehensive counseling on health.
Counseling	Open convo by acknowledge their interest in integrative medicine
	State your role of working with physician
	Provide opportunity for patient to voice any questions or concerns
	Explore underlying reasons for questions and concerns.analyze the questions and concerns.
	Expaln why some therapies without scientific backing may be harmful
	Introduce concept of integrative medicine for well-being, body, mind, spirit,
	Offer lifestyle assessment and recommend changes.
	Discuss therapies appropriate to patients concerns, situations and needs.
	Summarize key points of the conversation.
	Confirm patients understanding and that all questions have been answered.
	Document the encounter for paitents primary physician.
	Arrange follow-up visits to monitor adverse reactions and response to treatment.
	Adjust treatment plan as required.
Complementary therapies	A: Safe and helpful
	B: safe but not enough data if helpful
	C: Useful but with risk (herbals can be here due to side effect or interaction with other drugs)
	D: Harmful and no benefit.
Mind-body therapies that are safe:	Meditation, hypnosis, guided imagery, biofeedback,
	breathing, muscle relaxation, yoga, qigong, tai chi
Benefits	Reduce common emotional and psychological problems
	Stress reduction may have influence on the pathophysiology of disease thus improve outcome
	Helps caregivers to deal with the stress of caring for a chronically ill patient and build a nurturing family environment.
	Improve the well-being of the physician, making them more emotionally balanced and effective at work,
	more job satisfaction and better care for patients.(for caregivers/physicians who do mind-body therapies)
Mindfulness vs TM (Mantra) meta study	Comparison of meditation programs with nonspecific active controls (efficacy).
psychological stress and well being.	Anxiety- Mindfulness had a moderate improvement, while TM had low to no effect.
	Depression- Mindfulness had a moderate improvement, while TM was insufficient.
	Stress/Distress: Mindfulness had low improvement, while TM had low to no effect.
	Negative effect- Mindfulness had low for improvement, while TM was insufficient.
	Positive effect: Mindfulness was insufficient, while TM was insufficient.
	Quality of Life: Mindfulness was low improvement.
	Attention: Mindfulness was insufficient.
	Sleep: Mindfulness was insufficient
	Substance use: TM was insufficient
	Pain: Mindfulness had a moderate improvement, while TM was low to no effect.
	Weight: TM low to no effect.
	Overall the study did favor meditation over the control. 47 trials with 3515 participants,
	JAMA Intern Med. 2014 Mar, 174 (3): 357-68.
Yoga meta-analysis	Favors Yoga for Anxiety, stress, depression, QoL, Distress, Fatigue.
Massage therapy	Swedish, Reflexology, Lymphatic drainage, Myofacial release, shiatsu
	Tui-na, Reiki, Ayurvedic massage
	Best effects were mood and pain.
Acupuncture for cancer	Found to be effective for pain, nausea, vomiting
	Useful for: Hot flashes, insomnia, dry mouth, anxiety
	Exploratory: GI dysfunction, Lymphedema, Fatigue, Neuropathy.
Herbs and dietary supplements	Natural products are rich source of theraputic agents that are biologically active.(some drugs come from plant materials)
	Supplements are perceived as safe, not true in some cases, may have side effects of interact with other drugs.
	Some products are hyped up with unsubstantied claims and even fraudulent.
Phytoestrogens	red clover, kudzu, alpha-alpha, wild yam, resveratrol, grape seeds, fo-ti, dongquai, chaste berry, licorice
	Soy. Avoid soy isoflavone supplements. Food: low serving of tofu, soy milk, soy nuts, miso, soy protein, bean spouts.
Supplements	Read the fine print. Dose may be small
	Many have small amounts of active ingrediant.
Integrative medicne approaches	Patient centered: patients responsibility and ability in taking in an active part in their health care.
	Physician’s responsibility in inspiring and empowering patient to do so.
	Proactive: Emphasis on prevention
	Focus on fostering the body’s resilience in order to resist diseases and recover from illness.
	Holistic: recognize the importance of body-mind-spirit interaction in well being.
	Incorporate non-conventional therapies that have a favorable risk/benefit ratio.
Improve mental resilience	Attitude: stay positive, deflect negativity, be gently, be able to let go.
	Self-Improvement: remain true to yourself, joyfulness, meanings and priorities, spiritual growth.
Grading recommendation	A, B, C, D, H (against the service moderate or high it can harm), I (insufficeient evidence, need more study).
finally:	Be open and empathetic, evidence-based discussions of complementary therapies.
	help patients needs be understood. Lead them to reduced symptoms and better QoL.
	help them avoid hearmful therapies, enhance trust and rapport, strengthen the physician-patient relationship,
	improves the overall quality of patient’s care.
Safety in clinical practice	patients have complicated medical histories. Disease and conventional treatment cause a wide range of effects.
	anxiety and depression are common psychological comorbidities.
	Referrals to acupuncture in the inpatient hospital setting by MD/NP/PA for inpatients.
	Chart review: Physician notes- best source.
	Diagnostic tests: Radiology (CT scans, MRI, X-ray), Pathology, Recent blood tests.
	Oncology treatment history: chemotherapy, Radiation, surgery, additional medications.
acupuncture history:	Prior experineces, response, sensitivity to needles, phobia, size, manipulation,
	realistic expectation with acupuncture, prognosis and goals.
Precautions and contraindications	Thrombocytopenia- bleed risk. Platelet counts: normal is 160-400k/mcl. Cancer: 20 to 50 or <20 needle shallow or hold off.
	neutropenia- infection risk. WBC normal is 4.0 to 11 k/mcl. Low is 1.5 to 8.8 k. below 0.5 hold off.
	mental status issues: erratic behavior
	Fever/active infections
	Severe weeping edema
	Lymphedema
	Avoid recent surgical stie area
	Site of tumor or metastates
	area of recent XRT
	Thrombosis (DVT)
	Cardia arrhythmias, patients on pacemaker (no estim)
Medical devices	IV lines, PICC lines, NG tube, Medi-port, Hepatic artery pump
	EKG, BP, O2 monitoring, Ventilator, Catheter, Drain.
Surgical concerns	Patients can be heavily medicated following surgery
	Tissue expanders, ostomies, sutures, drains, surgical site- bandages, avoid local area
	Amputation- phantom limb pain, skin grafts.
Metastasis	Brain- cognitive changes or confusion
	Spine- avoid aggressive needling
	Pelvis- avoid deep needling and strong stim
	Skin- avoid skin lesions, decreased integrity, malignancy.
Emergent situations	Onset of SOB, increase HT rate by 20 bpm, Alert RN/MD.
	Document event, do not be afraid to ask for help.
Universal precautions	Treat everyone as if they could have HIV, HBV or other blood born pathogens.
	Hand washing, gloves, masks, gowns when appropriate.
	Hand: before touching patient, before antiseptic procedure, after body fluid exposure,
	after touching aptient, after touching patient surroundings.
	62% ethyl alcohol before and after acupuncture.
	Soap and water- hands are visibly soiled, dirty, contaminated. Before and after activities with risk of blood or fluids.
	Patients isoloated due to drug resistant infections. After bathroom, before eating.
	Ppe: gloves, gowns, masks, respirators. Remove before exiting the room.
	have good SOAP notes: intervention , service provided, clinical notes, patient visits, correspondence to professionals.
brachytherapy	Internal radiotherapy
	EMR/EHR records are best. Electronic charting.
Herbs and Drug interactions  (HDI)	30% of cancer survivors use herbs
	63% of cancer survivors with chronic illnesses use more that two supplements
	The average amarican uses 12 Rx drugs per year
	ADRs resulted in >100,000 deaths per year
	2004 the study of herbal effects on metabolism and other toxicity.
	Grapefruit and St. John’s wort can interact with drugs.
	Mechanisms can be traced back to co-evolution of pants and humans.
	PubMed only has about 1000 articles on herb interactions. Needs more clinical trials and studies.
top herbs	St. John’s Wort, Ginkgo, Kava Kava, Digitalis, Willow, asian ginseng, astragalus, licorice, saw palmetto, garlic
top drugs interacted	Warfarin, Insulin, aspirin, digoxin, ticlopidine, theophilline, cyclosporin, heparin, spironolactone, tamoxifen
FDA study in 2006:	75k calls to poison control: 275 were oabout dietary supplements, 112 signs of toxicity, 6 HDI, 3 ICU, 1 death (caffeine and yohimbe)
Herbs and Drug interactions  (HDI)	species, part of plant used, quality control, dosage, duration of use
Patients	Genetics, age, gender, disease state, liver and renal function, diet
Drugs	Dosage, route of administration, pharmacokinetics
Pharmacokinetic	absorptoion- distribution- metabolism- elimination
Pharmacodynamic	Herbs affect the pharmacologic properties of other herbs and drugs.
Absorption-	increases GI motility- decreaed absorption, pH- Ionization weak acid vs weak base, effects on enteric coated drugs.
	Solubility and physical compatibility: fat can increase lipophilic drug absorption, minerals and tannins from plants
	can bind with drugs and decrease their absorption.
	Blood flow- increase intestinal blood flow increase absorption.
Distribution	protein binding- drugs transported by binding to albumin. Only the unbound drugs are active.
	Herbs exibit higher affinity to proteins and displace drugs into the free (active) form resulting in:
	Increased toxicity and altered drug assay.
metabolism	Oxidation and reduction, congugation with glucuronate or acetate- water soluble metabolites,
	facilitates excretion of kidney urine and liver bile.
	inducers- increase enzyme or transporter activities.
	substrates- substances metabolized by microsomal enzymes or affected by transporters.
	inhibitors- decrease enzyme or transporter activities.
	Herbs can make treatment infeffective or it can Increase adverse events.
Juices with CYP3A4 inhibitory effects	Pomegrante, Pomelo, cranberry, seville orange, lemon
Interactions  cancer treatment	blood thinning herbs vs anticoagulants (warfrin: avoid garlic, ginkgo, ginseng, dong quai, st john wort, feverfew)
	Antioxidants vs chemo drugs (chemo drugs: avoid grape seed extract and pine bark extract)
	Phytoestrogens vs hormones (avoid ginseng, soy, dong quai, red clover)
	immunostimulants vs immunosuppressants. (avoid astragalus/huang qi for patient on immunosuppresants)
Manage interactions	Monitor high risk patients closely
	Adjust dosing intervals
	Change route of administration
	Change or discontinue one or both agents
	Enhance communication between healthcare providers and patients.
	Obtain relevant information.
www.aboutherbs.com
Integrative approach to Cancer prevention	reduction of caner mortality via the reduction of cancer incidence.
	Avoid carcinogens, smoking cessation,
	Change lifestyle and diet to modify cancer-causing factors
	Take medication to reduce risk of cancer (Chemoprevention), tamoxifen can prevent breast cancer in high risk women.
	screen for early detection to remove precancerous lesions (colonoscopy to remove polyps)
	Avoid radiation- use sunscreen, avoid unnecessary X-rays and CT scans.
	Treat or prevent infection- vaccine or Rx. HPV (cervical cancer), HBV, HCV (liver cancer),
	Epstein-barr virus (Burkitt lymphoma) H.pylori (gastric cancer)
Obesity	Postmenopausal breast cancer
	Cancer of esphagus, pancreas, colorectum, endometrium and kidney.
	Other: Coronary heart disease, diabetes type II, cancers, hypertension, dyslipidema, stroke
	Liver and GB disease, sleep apnea, osteoarthritis, gynecological issues.
	Reduce calories by 500-1000 per day.
	Increase physical activity, 30 minutes daily, moderate intensity.
	Behavior therapy- self monitor, stress management, social support, integrative therapies.
	Foods- red meat, processed meats, alcoholic drinks, sugar.
	More dietary fiber, more fruits, non-starchy vegetables, vitamin D
Physical activity	decreaes inflammation, decreae insulin resistance, reduce adipose tissue.
	increase cancer survival
8 things to help prevention	Body fatness: Be as lean as possible.
	Physical activity- limit sedentary habits, 30 minutes vigorous physical activity.
	Foods: avoid high calorie foods, sugary drinks, fast food, energy drinks.
	More pant foods- increae servings to 5, unprocessed grains, legumes, limit starchy foods.
	Reduce red meat, pork, lamb, salted foods, smoked foods.
	Limit alcohol drinks.
	Aim to meet nutritional needs through food and less with supplementation.
	www.mskcc.org/aboutherbs

Survivorship	Cancer survivors are seeking the best path to change their lifestyle and improve their overall healthy,
	as well as decrease their risk of cancer recurrence.
	Survivorship definition: having no signs of cancer after finishing treatment.
	Living with, through nad beyond cancer.
	Begins at diagnosis, through treatment to the rest of person’s life.
Transition	Period of time leading up to completion of therapy through initial phase afterward.
	Individuals living with advanced or metastatic disease are often overlooked as candidates for rehabilitation.
	Rehabilitation and survivorship support includes physical therapists, occupational therapists, and speech-language pathologists.
Survivor statistics	16.9 million people with a history of cancer living in the US on Jan. 1, 2022.
	Cancer survivors in the US , expected to reach 22.1 million by 2030.
	Survival often comes with physical, psychosocial and financial burdens.
Cancer Rehabilitation	Many Cancer networks (NCCN, ACS ACCC, etc.) now identify rehabilitation as a crucial if not mandatory component of cancer care.
	Many centers do not have organized programs for cancer rehab.
TCM/Acupuncture/herbalist	can be a component of usual care to help patients suffering from late effects caused by cancer and its treatments.
	We can assess health status and subtle changes in our patients in frequent time points.
	We can provide whole system individualized care that can address multiple complaints simultaneously.
	We tend to have regular contact with our patients so are able to provide ongoing evaluations of potential changes or
	signs of recurrence.
Fear of cancer recurrence (FCR)	Lifestyle factors can be related to FCR. High FCR in patients who were smokers, low FCR in patients who had healthy habits.
	Physical activity, “5-A-Day” (servings of fruit and veggies), quit smoking.
Chemotherapy/drugs side effects	chemo brain, heart conditions, thyroid problems, lung damage, infertility, Osteoporosis, hearing loss
	Cataracts, secondary cancers, peripheral neuropathy, impaired immunity
Radiation therapy side effects	Hyper/hypo thyroid, hearing loss, vision problems, dry mouth, brain or thyroid cancer, osteoporosis.
Radiation to the chest	Lung damage, breathing difficulties, heart damage, osteosarcoma, breast cancer, thyroid cancer, hyper/hypo thyroid
Immune therapy- still new and learning	Car T-cell therapy, B-cell aplasia and resulting hypogammaglobulinemia, as well as prolonged cytopenia’s and infection risks.
	ICI- immune checkpoint inhibitors: nivolumab, pembrolizumab, atezolizumab, ipilimumab.
Assessing the patient
factors to consider	Type of Cancer, cancer treatment, location of tumor, common sites for metastasis, age and health at diagnosis, TCM constitution
	Collect patients experience of symptoms prior to cancer diagnosis and treatment, during cancer treatment, and present.
	No two patients are the same, it will be common their medical presentations will be hard to understand.
Cancer Recurrence	Conventional medicine does not have a tool to predict recurrence in a particular patient.
	Patients will be put on a schedule for follow-up. Annual change for 5 years post treatment.
	It is important for us to keep a close watch on any changes in the patient’s presentation.
	Some cancers have a higher rate of recurrence than others.
	Each cancer has different monitoring.
	Conventional medicine does not emphasize lifestyle counseling.
Metastasis	Know where cancer tends to spread.
	Be mindful of early symptoms of cancer in distant areas, be first to recognize this.
	Include inquiry and assessment of these sites in survivor patients.
Red Flags	Loss appetite, weight loss/changes, night sweats, fatigue, and pain.
Symptoms of metastasis	Brain: headaches, seizures, nausea, vomiting, weakness, confusion, visual disturbances
	Bone: local pain
	Liver: rt. Side abdominal pain, jaundice, fatigue, weight loss, nausea.
Understanding of survivors of Cancer.
Breast Cancer	Most common non-skin cancer, second leading cause of death, survival remains steady since 2000.
	side effects: GI complaints, lymphedema, cardiac toxicity, reproductive dysfunction, neuropathy, skin changes, skin changes
	radiation fibrosis, fatigue, hot flashes.
	5 year survival is 89%, cancer can move to lung, liver, bones, brain.
	Recur around surrounding area lymph, look for swelling under the arm, collarbone, neck. Changes in skin, thickening or redness
	Cognitive dysfunction, bone loss, neuropathy, endocrine disruptions, infertility, sexual health issues, body image concerns.
risk factors	Breast traversed by liver channel and stomach channel through nipple
	Chong and ren dysfunction
	Chronic constraint
	External pathogen like wind-cold invasion bind with blood for form lumps
	Fire toxins invade organs to cause inflammatory breast cancer
	Damp invasion
	Over work, overwhelmed, unresolved grief, unexpressed emotions
	Cold foods damaging spleen.
hot flashes	Hormonal treatment, chemotherapy induced ovarian failure, ovarian suppression therapy, surgical menopause.
	Frequency, severity, triggers, time of day, symptom journal.
	sweat pattern, temperature before and after.
DX	Qi stagnation, blood stagnation, damp accumulation, Yin deficiency, shao yang disharmony, Qi level heat.
Prognosis	Usually by treatment 4, goal minimizes symptoms.
Colorectal Cancer	Increased screening has led to early detection.
	decrease in QOL
	effects: fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy,
	GI problems, urinary incontinence, sexual dysfunction.
	1.4 million survivors, 90% survival with early detection
	tends to met in liver and lung or abdominal cavity
	sx of local recurrence: frequent stools, thinner stools, feeling incomplete bowel movement,
	blood in stool, loss of appetite, abdominal pain or fullness.
	side effects: bowel or bladder dysfunction, sexual dysfunction, peripheral neuropathy, mental health, risk of pelvic fracture, cardiotoxicity.
Leukemia	acute lymphocytic (ALL)
	chronic lymphocytic (CLL)
	Acute Myelogenous (AML)
	Chronic Myelogenous (CML)
	Mortality down 1% each year since 2000 to 2010
	late effects: fatigue, risk of another cancer, early cardiac disease.
Blood Cancers	majority of leukemia relapses occur up to 2 years after treatment.
	look for bruising, swollen lymph nodes, bone or joint pain, recurrent infections.
Lymphoma	Hodgkins- mortality decreased by 70% since 1975. Incidents the same
	Non-Hodgkins: mortality decreased; incidence decreased
	Late effects: increase risk of other cancers for up to 20 years, early cardiac disease
	Lung disfunctions, xerostomia, hypothyroidism, infertility
Lung Cancer	Primary cause of cancer related death, mortality declining since 2001,
	late effects: Lung dysfunction, pain, neuropathy, fatigue.
	Tends to met to brain, bone, liver
	Recurrence symptoms: coughing, blood in sputum, shortness of breath, wheezing, pain in chest
	Fatigue, pneumonia, CIPN, depression.
	risk factors: EPF invade lungs and impair diffusing and downward bearing, toxic heat leading to yin vacuity
	exuberant phlegm-damp, emotional depression, chronic spleen vacuity.
Prostate Cancer	most common non-skin cancer, second leading cause of death in men
	Incidence rose dramatically when began to use PSA test
	90’s mortality has declined.
	Late effects: erectile dysfunction, urinary and bowel trouble, infertility
	5-year survival is 95%
	Tends to spread to liver, lungs, bones (hip, spine, pelvis), and lymph
	30% can relapse after 5 years. PSA increases after treatment.
	Urinary, sexual or bowel dysfunction.
	ADT can cause increased risk for obesity and diabetes as well as cardiovascular disease
	Bone density loss.
Gynecological cancer	Ovarian- tends to met to bone, liver and brain.
	70% of ovarian cancers recur (50% within 3 years).
	Abdominal swelling or pain. Urinary changes if it compresses the bladder.
	Uterine- tends to met to the lungs, bones, brain, vagina, pelvic organs
	88% recurrences in first 3 years
	More than 50% are symptomatic.
Childhood cancer survivors	Late effects of childhood cancers: death if primary cancer returns, second malignancy, Heart and lung damage from treatment.
	Need to know patients’ history since many late effects develop years later.
	Comon late effects: Organ, tissue and body dysfunction, growth and development delay
	Depression, anxiety, challenges with learning and memory, social adjustments, risks of secondary cancers.
Late effect symptom management	Cardiac Toxicities: chemo drugs Trastuzumab, Doxorubicin, Daunorubicin (Cerubidine)
	Eprirubicin (Ellence), Cyclophosphamide (Neosar).
	high blood pressure: Bevacizumab (avastin), sorafenib (Nexavar), Sunitinib (Sutent).
	Chemo brain- affects anyone who has had chemotherapy, becoming a late-effect. Difficult thinking, concentration, memory.
	Fatigue: most common reported, can go on for years, 25% more common in women.
	Hot flashes: caused by medically or surgically induced menopause
	Lymphedema: common after lymph node removal in breast surgery, high risk of infection on affected limb.
	Xerostomia: radiation effect, difficult to treat, start treatment as soon as possible.
	Sexual dysfunction: erectile dysfunction, vaginal dryness, pain with intercourse, body issues, hormonal changes.
	Neuropathy- begins during treatment and becomes chronic, further away from treatment can make recovery difficult.
	Fear/anxiety: recurrence can be severe, “watch and wait” up to 5 years or more, Shame.
	insomnia: Often begins during treatment and continues in survivorship, related to treatment or anxiety.
	infertility: patients can bank egg and sperm before treatment, loss of fertility can be devastating.
	pain: chronic pain is common, 40% reported, screen for pain every visit, recurrent diseases, second malignancy,
	important to consider using a validated pain measure in survivors.
	Pain Red flags: new onset should be evaluated, assess patients’ opioid use, consider referral to MD for screening.

Hospital Based Practice	Columbia university Dept. of Pediatrics
	Michelle Bombacie NCCAOM, Lac, LMT. Kenna Bouvet, Lac, CPT
	overview of policies, procedures, practice guidelines in hospital based integrative medicine center
	Intgrate acupuncture and communicate collaborative approach with a convential cancer setting
	Needle education and research
	Implementation of this model through case presentations.
	Risks scenerios and still being effective.
	JCAHO: Joint commission on Accreditation of Healthcare Organization
	WHS: Workplace Health and Safety. Infection prevention, , HIPPA, OSHA training. Contact isolation example. PPE
	NIH. National Center for comlimentary and Integrative health.
	NIH: Acupuncture: Mind body category (acupuncture, qigong, Massage, yoga) EBM, Whole systems. (ayervedic,osteopathy, TCM, chiro, PT)
	Credentialing: state license, Malpractice insurance, NCCAOM, Course work on patient population.
	Education: doctorat, Masters, etc., years of experience.
Standard Operating procedures (SOP)	new patient recruitment, consenting patients
(nutritionist, yoga instructor, etc.	Ititianl tratment planning, Ongoing tratment planning
	Acupuncture specific protocols
	Patient assessment for acupuncture
	Patient encounter requirements
	Patient tracking and charting
	Daily logs
	Wellnes program
Supportive care guidelines	Recommendations and strength and quality of evidence
	best practices
	Hiqh quality: confident in the estimate of effect
	Moderate quality: further reseasrch as important impact of confidence of effect
	Low Quality: further research very likely to have a imprtant impact on confidence of effect.
	Very low quality: estimate of effects are uncertain
Chemo Ind. Nausea Vomit (CINV)	acupuncture strongly recommended. Hypnosis, systemic desensitization, or relaxation techniques (MBSR)
Fatigue	acupuncture strongly recommended. Physical activity, systemic desensitization, or relaxation techniques (MBSR)
EMR	collects data. Platelet assessment, signs/symptoms, TCM diagnosis
	5 phase diagnosis, treatment plan, advesre events, total needles in/out, retention time, technique, needle type.
	Points used, extra, ears, unilateral, bilateral.
Scales (pre and post acupuncture) 1-10	distress like Anxiety (1-10)
	Nausea and vmiting
	Pain (1-10)
	Fatigue
	Neuropathy
	Other
RASCAL	Research compliance and administration . IRB institution review board
	Allows to create protocols, appendicies, COI’s (conflict disclosure) create HIPPA and consent forms.
Thrombocytopenia	acupuncture was fine considering low platelents, no infections or excess bleeding reported
Neutropenia	low WBC count, there was no infections were reported from acupuncture
Integration and translation of acupuncture
Integrative Therapies program	nutritioninst, acupuncturist, physicla therapist, occupational therapist, research corrdination.
	acupuncture, acupressure, aromatherapy, exercise and movement, massage, mnd-body medicine, nutiritional counseling
CIHT (complementary integrative health therapies)	Natural products
	Deep breathing and breath work
	Acupuncture, Acupressure
	Aromotherapy acupoint therapy (Jeffery Yuan method)
	Yoga, Tai Chi, Qigong,
	Chiropractice and Osteopathic services
	Meditation
	Massage, canial sacral, Reiki, reflexology, Tui-na
	Heat, kinesio tape
	Special Diets
	Homeopathy
	Progressive relaxation
	Guided imagery
Typical day in clinic	Patient check in, triaged and labs, visit with NP or oncologist, if patient makes counts then chmo is ordered
	RN assess patietn, visit with psychologist, visit with nutritonist, visit with intgerative therapist,
	If patient does not meet counts they only see CCQ or ITP
Acupuncture to patient	Acupuncture stimulates acupoints on meridians on surface of body. Neurotransmitters modulate pain chemicals,
	acupuncture regulation of activity of pain sensation, changes brains processing of informaiton and neocortical, limbic, and brainstem levels.
	it alters purinergic signaling, treatments are individualized on constitutional and circumstantial (root and branch).
Assessment approach to treatment	Root treatment: support earth (kids weak ST/SP), fear, fright, (kidneys), Fu zheng Pei Ben (upright Qi, prevent cancer growth) principle.
	Acute treatment: symptom managemtn ans patient is experiencing it
	Prevention: understanding treatment protocol and working to prevent chemotherapy
	Chronic: persistent symptomatology
	Zang fu: yin/yang organ pair involved or influenced
	Meridians: pathway trajectory: what organ system to they enter and/or encase
	Substances: What substances are involved in diagnosis of treatment protocol
	5 element: depending on age, observation of being.
TCM Oncology	Blood level Xue: Leukemias. TCM: heart governs, Liver stores and regulates, spleen contains.
	Marrow: Leukemias, Brain and CNS tumors. TCM: Kidney, extraordinary organ, Brain.
	Phlegm: Solid tumor, Lymphomas. TCM: Spleen, blood stasis, Kidney, Liver.
Jin shen pediatrics (5 phase observation)	water: 1-3 monthsn, 6-7 years, 13-14 years
	wood: 3 months to 1 year, 8-9 years, 15-16 years
	Fire: 1-2 years, 9-10 years, 16-17 years
	Earth: 2-3 years, 11-12 years, 17-18 years
	Metal: 4-5 years, 12-13 years, 19-20 years.
	water: flexible, slow, observer, delayed milestone, fearful, imaginative, withdras easily
	Wood: action, very active, quick temper, restless, assertive, thrills, frustrated
	Fire: bright, active, entertainer, seeks stimulation, magnetic quality, overexcited, dramatic
	Metal: detailed, organzied, sensitive, routine, aesthetic sense, hyper focuses, rigidity
Assessment: approach to Tx	Emotion
	Physiology
	Structure
Side effect prevention:	pain, anxiety, constipation, headache, URI, UTI, immune weakness, appetite, CIPN, mucositis, scars, sleep difficulty, trauma response
	radiation: anxiety, burns, skin sensitivity, dryness, brain fog
	surgery- amputation, prosthesis, posterior fossa syndrome, tumor resection, ventrical peritoneal shunt. Anxiety, pain, scarring.
	Procedure: lumbar puncture, Intra oral chemotherapy, port placement, scans, transfusions. Anxiety and pain.
medical team check-in (Red flags/Cautions)	ANC < 0.5 k/mcl
	Platelets <20k
	blood clots
	unstable vital signs
	tumor break through/ metastatic site
	anatomical changes and scar tissue associated with surgery
	change in medical diagnosis
	C-diff
Needle type	Pyonix, or smallest seirin needle for kids.