Supporting Patient and Provider Well-Being

Transcript

00:00 --> 00:21Announcer Funding for Yale Cancer answers is provided by Smilow Cancer Hospital. Welcome to Yale Cancer Answers with the director of the Yale Cancer Center, Doctor Eric Winer. Yale Cancer Answers features conversations with oncologists and specialists who are on the forefront of the battle to fight cancer. Here's Doctor Winer.
00:21 --> 00:56Eric Winer This evening, I'm talking with our guest, Doctor Jennifer Ligibel, who is a professor of medicine at Harvard Medical School and a senior physician at Dana-Farber Cancer Institute, where she is both a breast cancer expert. And also leads two very important programs. One is the program at Dana-Farber, that focuses on integrative therapy and healthy living. It's the Leonard Zakim Center for Integrative Therapy in Healthy Living.
00:56 --> 01:25Eric Winer And the second is a program focused on clinician wellness. And we'll be talking about the importance of that in the second half of this show. So let's talk about something that people with cancer and people without cancer talk about a lot, which is integrative therapies, sometimes called alternative therapies. In the past, I think we think of it a little differently today.
01:25 --> 01:32Eric Winer And, maybe you could first just talk about what integrative therapies and what integrative medicine is.
01:32 --> 02:10Jennifer Ligibel Absolutely. So and I think these are some important distinctions, when we think about the best ways to support our patients. Integrative therapies are treatments that support the whole patient and are really given alongside things like chemotherapy, radiation, surgery, some of the traditional Western therapies that we provide to our patients. Integrative therapies really focus on mitigating the side effects that are associated with a lot of our cancer therapies, improving quality of life, and really trying to give people their lives back sometimes after they've finished cancer therapy.
02:10 --> 02:29Jennifer Ligibel Alternative treatments are a little bit different, and these are often therapies that are given in place of standard cancer treatments. Integrative therapies are not a replacement of chemotherapy or other proven therapies that we know help our patients, but they're given as adjuncts to these treatments.
02:29 --> 02:53Eric Winer Well, that's, an important distinction. And I think in the past when people talked about alternative therapies, they really were talking about, you know, going off to Mexico and getting way of travel, and not pursuing standard therapies as well. Can you talk a little bit about the range of integrative therapies?
02:53 --> 03:21Jennifer Ligibel There really isn't an official list of what qualifies as an integrative therapy. And, you know, there are some definitions that are so broadly based that they include spirituality and prayer and all forms of exercise and different kinds of diets, and then others that are a little bit more, restricted to things like acupuncture and massage and things like tai chi and yoga.
03:21 --> 03:39Jennifer Ligibel So, you know, I think that the general concept, again, is things that people do to improve their outcomes, the way that they feel, the way that they respond to treatment in terms of their side effects, in conjunction with their cancer therapy. So that can be different things for different people.
03:40 --> 04:07Eric Winer Patients often ask me about these things, you know, what's what's safe and what isn't safe. You know, I always say that yoga, massage, acupuncture, which is actually proven to be beneficial in certain areas and maybe I'll touch on that. Those are all pretty safe approaches. I sometimes get worried about the different types of vitamins and supplements and other sorts of things.
04:07 --> 04:08Eric Winer People take.
04:09 --> 04:39Jennifer Ligibel There's, you know, there are a variety of things that people seek out, oftentimes with the goal of treating their cancer. And I will say that with very few exceptions, there's not a lot of evidence that things like supplements or medications that are taken off label, that are prescribed for other purposes or in veterinary situations have anti-cancer effects.
04:39 --> 05:00Jennifer Ligibel That being said, I think that many people are seeking some ability to have control. Cancer is a really difficult time in people's lives, and there's a sense of loss of control. And so I think that sometimes people look to these types of products, to have a feeling that they are playing a more active role in their care.
05:00 --> 05:35Jennifer Ligibel And again, I think there's this important kind of distinction between things or two people are doing as an adjunct and things that people are doing in place of their standard cancer therapy. There are very good data that when people choose to kind of skew standard therapies and only pursue alternative treatments, that their outcomes are quite poor. And there are many hospitalizations in the U.S. every year related to overdoses and interactions between things that people take as supplements, often with the sense that, well, they're natural.
05:35 --> 05:59Jennifer Ligibel They couldn't be harmful. So I think the other part that's important for our patients, especially those who are undergoing active therapy, is that there can be a lot of interactions between these supplements and other things, and especially the newer targeted oral anti-cancer therapies, those need to be absorbed. There's a complicated dynamics in the liver about their metabolism.
05:59 --> 06:35Jennifer Ligibel And so, you know, we actually at Dana-Farber have an integrative therapy clinic where a pharmacist, works full time to really go through the lists of supplements and things that people want to take, really to look at safety. I think that, you know, again, there's not evidence that these kind of products do treat cancer. But I also feel like people need to have autonomy and choice and so my goal in this situation is to make sure that people aren't going to harm themselves or undercut the efficacy of their cancer treatment by taking these products.
06:35 --> 06:59Eric Winer In my own practice. When someone wants to take one of these oral supplements, particularly in conjunction with other therapies, other active cancer therapies, I try to make sure that it's not something that's going to interfere. Of course, the simplest thing is just not to take it. But I agree with you that you know, people people want autonomy.
06:59 --> 07:23Eric Winer And, you know, if I can't say for sure that it's, that it's not going to help, you know, because there's always the possibility, I guess. Then, you know, I understand why people do it personally. I would tend to avoid most of these things, but, you know, maybe you can touch for a minute on the ones that are most problematic.
07:23 --> 07:34Jennifer Ligibel You know, and I think that this is a bit of a moving target. And the other piece of this that is complex is that very few people are taking one supplement. There is.
07:34 --> 07:35Eric Winer Many.
07:35 --> 08:04Jennifer Ligibel Right. So there is a really nice database that Memorial Sloan Kettering, maintains that talks about interactions between supplements and anti-cancer therapies. But what is really complicated is that generally they look at kind of one supplement at a time. And many people that are interested in this path are taking a long list of things, and there's almost no information about how those different types of supplements interact with each other.
08:04 --> 08:25Jennifer Ligibel And so I think that's where it really gets complicated and where I really lean on my pharmacy colleagues. Anti-Cancer therapies are prescribed in a pretty narrow range. And if you start having very, very high levels of those because you're, oh, you know, all of the enzymes in your liver are busy metabolizing other things, you may run into pretty significant difficulties with toxicity.
08:25 --> 08:50Eric Winer And, you know, in recent years, when people had to take standard medicines, and you go to a single pharmacy, there's a computer in the pharmacy, you know, that that looks for these, the interactions and problems that can arise. And that, of course, doesn't happen when you combine anti-cancer therapy with some of these supplements. And that's for that.
08:50 --> 08:53Eric Winer That, of course, is what your pharmacist is trying to do.
08:54 --> 09:12Jennifer Ligibel Right. And I do think it kind of brings up an important point is that as a patient, it's so important to speak with your oncology team about everything that you're taking. I think sometimes people don't want to share these things because they're afraid they're going to be told not to take them, or in their A variety of other reasons.
09:12 --> 09:26Jennifer Ligibel But it's just so important to talk about what you're interested in doing and what you're taking, so that we can make sure that things are safe and that the cancer medicines that people are taking are also prescribed appropriately.
09:26 --> 09:50Eric Winer Well, and it's not just the patients who may be reluctant to talk about it. Oftentimes, the ecologist doesn't even really want to hear about it because they're not quite sure what to say. So I think it goes both ways. And I think it's something that we really have to work to make sure that we, we know what people are taking in and again, make sure that it's not causing any harm.
09:50 --> 10:08Eric Winer But this is why, I'm always much more comfortable with things like massage and exercise. And we can talk about exercise in a minute and acupuncture. Maybe you can talk for a minute about what acupuncture has been, where it's been shown to be beneficial.
10:08 --> 10:36Jennifer Ligibel Absolutely. And I think this is a really important point. And that when patients do come in with kind of long lists of supplements and things, they're taking, you know, I really often try to direct people toward, well, where is there evidence of benefit? And acupuncture is absolutely a place where there is a growing body of evidence that acupuncture is very effective in treating many of the side effects that patients experience during their cancer treatment.
10:36 --> 11:05Jennifer Ligibel There have been large, well-designed randomized trials showing that acupuncture reduces the joint pain that women experience as a result of aromatase inhibitors and other anti estrogen treatments. There are studies showing improvements in hot flashes and in chemotherapy induced peripheral neuropathy. There's a very large study that's just finishing up now, at Dana-Farber and Memorial Sloan Kettering that will look at that in more detail, led by my colleague Ting Bo.
11:05 --> 11:31Jennifer Ligibel You know, I think that there's also a fair amount of evidence for other types of pain that patients with cancer experience that acupuncture may be beneficial, for treating those. So I think, you know, when you look across the randomized data coming from the integrative medicine field, acupuncture really is the best study treatment for really managing many of the side effects that our patients experienced during their treatment.
11:32 --> 11:58Eric Winer Maybe we could touch on, diet and exercise, which I guess you could either argue that those are integrative therapies, or maybe they're not, because they're just what we do, but I think that they fit in this general group of ways in which people can potentially help themselves in a nontraditional manner. Tell us what we know about diet and exercise.
11:58 --> 12:35Jennifer Ligibel This is definitely a place where people can take, can be empowered to make changes that we have very strong evidence can impact their outcomes, not just how they feel, but can actually affect their risk of developing cancer and their risk of cancer recurrence. Exercise in particular. Now, in randomized trials, there was the challenge study, that showed that a structured exercise program after colon cancer treatment reduced the risk of recurrence, improved mortality outcomes, and, interestingly, had a strong impact on preventing new breast and prostate cancers.
12:35 --> 13:04Jennifer Ligibel So really, really promising data for the anti-cancer effects of exercise. But there are also hundreds of studies that show that if you exercise during your treatment, you are more likely to maintain your strength in your function. You're less likely to be fatigued, to become anxious or depressed. So there's just so many benefits of exercise. If you have breast cancer and you do structured strength training, you're less likely to develop lymphedema.
13:04 --> 13:11Jennifer Ligibel So there's just so much data suggesting that exercise is beneficial. Diet is trickier. I'm going to be.
13:11 --> 13:29Eric Winer I'm going to interrupt you for a second because we're going to have to take a break. And this is not something we can cover in a minute. So we will pick up on this when we come back. Again, I'm with my guest, Dr. Jennifer Ligibel professor of medicine at Harvard Medical School. We'll be right back.
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14:51 --> 15:14Eric Winer Welcome back to the second half of Yale Cancer Answers. This is Eric Winer, and I'm here with my guest, Dr. Jennifer Ligibel, who is an expert in integrative therapies. I want to just ask you one question about exercise before getting to diet. And that is, to what extent does exercise for somebody with cancer, an exercise program?
15:14 --> 15:28Eric Winer To what extent does that that need to be supervised, prescribed? I mean, is this something that people should be just going off to their gym and deciding what they're going to do themselves? Or is it helpful to have some sort of guidance?
15:28 --> 15:55Jennifer Ligibel So that is a terrific question, and one that is the subject of an enormous amount of research across the U.S. and beyond. We know that cancer survivors, patients undergoing treatment may have barriers, limitations that may impact the way that they're able to exercise safely. And so there's a lot of work that's going on looking at, well, how do we triage people?
15:55 --> 16:24Jennifer Ligibel How do you figure out if somebody could go and exercise on their own or if they need something supervised, like physical therapy or occupational therapy or something in between, where they need a program that specifically overseen by somebody with expertise in exercise and cancer, is there are certification programs for people in this area. So, you know, I think that the first step is always talk to your doctor and see if they have concerns.
16:24 --> 17:01Jennifer Ligibel People that have advanced disease, I think, in particular really need to kind of talk to their oncologist about any limitations that they may be experiencing. I think for the average patient, getting out and doing something like walking is safe for most people. When you start to think about more intensive treatment or, sorry, more intensive training, or strength training, those are really areas where working with a professional for some people, especially if you don't have a history of exercise or if you've gone through therapy that has resulted in functional limitations like surgeries that have limb implications or you have an ostomy.
17:01 --> 17:23Jennifer Ligibel Those are really situations where you might want to seek out a professional. You know, I think the other thing in terms of like, where do you start? There are some really nice guidelines from the American College of Sports Medicine that talk about, well, how much exercise do you need to do to start seeing benefits? And it kind of looks at like how much aerobic exercise or how much strength training to see a benefit for something like fatigue or depression.
17:23 --> 17:25Jennifer Ligibel So that's also a place to start.
17:25 --> 17:42Eric Winer So diet is a little tougher. And you know, it's something that people think and talk a lot about a lot of individuals who have cancer changed their diets in one way or another. What do we know about the impact of diet?
17:43 --> 17:55Jennifer Ligibel So diet is definitely more complicated. And a few years ago we looked at all the evidence about exercise and diet interventions during treatment as part of an Asco guideline.
17:55 --> 18:02Eric Winer That was the American Society of Clinical Oncology. Just for those who are not familiar with with the name.
18:02 --> 18:26Jennifer Ligibel So we were really interested in what is the evidence say about changing your behavior during your treatment? What where are the benefits? And there was very clear evidence that starting an exercise program, maintaining exercise during treatment had concrete benefits for patients in terms of reducing their side effects and improving their function when they were finished with their treatment, there were not consistent data for diet.
18:26 --> 18:58Jennifer Ligibel You know, the studies were small. They tested different things like fasting and cutting carbs, and there was no consistency. And there was really no evidence from those studies that making dietary changes during treatment had benefits for patients. I think the only thing that we were able to say as a group was that this sort of thought that people shouldn't eat raw vegetables or fruit, during cancer treatment, because the risk of infection that there was no scientific basis for that, even for people with hematologic malignancies.
18:58 --> 19:23Jennifer Ligibel So we were able to say, you know, the benefits of eating fruits and vegetables far outweigh any infection risk. But there really wasn't clear guidance for what people should be eating during their treatment. Most of the evidence that connects diet to cancer comes from observational studies, where we're following big groups of people and we ask them what they eat, and then we see, well, who develops cancer and who doesn't, and whose cancer comes back and who doesn't.
19:23 --> 19:44Jennifer Ligibel Most of those studies suggest that diets that we think of as healthy lots of whole grains, fruits and vegetables, lean protein sources are linked to better health. But there really, you know, there have been a few randomized trials that have tried to look at specific diets and how they might impact cancer outcomes, in particular in breast and prostate cancer.
19:44 --> 19:59Jennifer Ligibel And those really haven't shown beneficial results. So I think diet remains a bit more of a mystery. It's something that we need to study. And it's unfortunate because that's really the most common thing. People come and ask me during their cancer treatment and.
19:59 --> 20:26Eric Winer Afterwards when they eat, what can I eat? Yep. I always I think the one thing that we can tell people is that, and this is a problem for some people, is that gaining a lot of weight during treatment is something that could have a negative effect. And of course, with some of the medications we use, it's sometimes hard for people, but to the extent that people can, they probably shouldn't gain a lot of weight.
20:26 --> 20:28Eric Winer Would you agree with that?
20:28 --> 20:41Jennifer Ligibel I would agree with that. It can be very complicated because people feel tired. You know, this is another place where exercise can be helpful. But I think trying to keep your weight in a healthy range during and after cancer treatment is important for people.
20:41 --> 20:50Eric Winer So mindfulness or meditation has been shown to be helpful in some situations. Can you tell us about that?
20:50 --> 21:18Jennifer Ligibel Absolutely. You know, when you look across the evidence for where do integrative therapy help? I think the two places where you really see strong evidence are for acupuncture and for meditation and mindfulness. And there has been many studies that have shown that meditation and mindfulness are very helpful for mental health, for reducing anxiety, for reducing stress, for helping improve quality of life.
21:18 --> 21:40Jennifer Ligibel I think the nice thing about meditation and mindfulness is that this has become so widely available with different apps and structured programs. So, you know, this is something that is sometimes more easily available to patients with cancer than some of the structured exercise programs and things like that. But very strong evidence for mental health benefits of meditation and mindfulness.
21:40 --> 22:04Eric Winer Well, I think that's something we should all keep in mind. I want to shift, the discussion a bit and just end in our last several minutes talking about, clinician physician wellness. There has been, of course, a great deal of discussion about burnout in doctors and nurses. I mean, for that matter, and all sorts of people in our society.
22:04 --> 22:15Eric Winer But we're going to we're going to focus on doctors and, and other health care professionals. What's going on with burnout and what can we do to help with it?
22:16 --> 22:46Jennifer Ligibel Know, I think you point out something that's really important is that, you know, we see the term burnout a lot, in the press related to many, many different fields. There's sort of a specific definition of burnout. What do you think about health care providers and other people that are really dealing with the public? You can see this in teachers and in, first responders, but it's this syndrome where people become emotionally exhausted and they kind of lose the humanity.
22:46 --> 23:15Jennifer Ligibel There's this sense of depersonalization of the people that they're working with. And then there's this kind of third piece of this that no matter how hard you work, you really have this sense of low personal accomplishment. This has been really described in health care workers increasingly over the last few decades. And, you know, estimates suggest that up to about a third of the oncology workforce really meets the definition of having burnout.
23:15 --> 23:38Jennifer Ligibel And we know that this is obviously a bad thing on an individual level. People that are burnout are more likely to be depressed. It has an impact on people's family lives, but it also has an impact on patients. There's very strong evidence that when clinicians are burned out, there are more patient complaints, there are more medical errors, people are more likely to leave their jobs in medicine.
23:38 --> 23:44Jennifer Ligibel And that creates big issues for people in terms of access to health is already a huge problem.
23:44 --> 24:07Eric Winer So this is this is big. And of course, it's really just common sense that a burnt out doctor or nurse wouldn't be able to provide the same high quality care for someone who doesn't feel that way. And that's something that patients can pick up on. And it's a challenge. So what can we do about it?
24:07 --> 24:32Jennifer Ligibel It's a bit of a complicated question, actually, because there's a lot of different forces that are causing clinicians to be burnt out, and some of it is inherent in our health system and the way that the reward systems are embedded within our health system. In medicine, unfortunately, or, you know, is a is a big business. And that puts pressure on people that are, delivering care.
24:33 --> 24:33Jennifer Ligibel You know, I think that.
24:33 --> 24:34Eric Winer More than ever.
24:34 --> 24:57Jennifer Ligibel Before, there are huge administrative burdens. There is a lot of red tape that is required in getting the care for your patients that you want. There's this term of moral injury where people are not able to do the things for their patients that they believe are most appropriate because of insurance and other restrictions that people don't have there.
24:57 --> 25:16Jennifer Ligibel There's so many pieces to why people are burned out that there's not a simple solution of we just need to do x, Y, or Z. But there are a number of different kind of when you think about how you develop a program or an initiative to try to reduce burnout, you kind of think about three major factors.
25:16 --> 25:45Jennifer Ligibel And this is part of this, Stanford model of occupational. Well, and it kind of talks about the individual factors, you know, how do you support the individual? The reality is clinicians are incredibly resilient people, and people are not burned out because they're not strong. They're burned out because the systems don't support them. So another big piece of this is looking at how well an institution systems support the work of the physician and the nurse and all of the clinical team.
25:45 --> 26:20Jennifer Ligibel And then the other piece really gets to the culture of the institution. Do people have a say in decisions that are important to them? Do people feel valued? Does leadership really know who the people that they're leading are and know what's important to them? And so they're kind of all of these pieces. And the reality is that although a lot of the things that drive burnout are these systems level factors, many times, what makes people happier in their jobs are it's the local environment around them so important, making sure that they have strong leadership and that they feel the support of their colleagues.
26:20 --> 26:27Jennifer Ligibel That can be incredibly important. Even if we can't fix some of the bigger issues that we face in health care.
26:27 --> 27:01Eric Winer Do you think that in oncology, where of course, we're taking care of patients who at times are very sick, many times do very well and are and are cured or live extremely well with an illness for years and years. But there are also people with cancer who, as we know, lose their lives from cancer and and I think in oncology just on average sees more, more people suffering and dying than the average physician.
27:01 --> 27:06Eric Winer Do you think that's a cause of burnout in the colleges?
27:06 --> 27:34Jennifer Ligibel You know, I think it's a great question. And we actually presented some data last year at Asco. Again, the American Society of Clinical Oncology, their annual meeting that looked at burnout in medical oncologist compared to general internists and to other internal medicine subspecialists. And what it showed was that levels of burnout were a little bit higher in oncologists compared to other types of internists, but their professional fulfillment was higher.
27:35 --> 27:57Jennifer Ligibel And there was a sense that some of that was related to the sense of value that they felt in their work, and that gratitude from patients. You know, and in that survey, the things that were closest related to burnout, were things like control over schedule. So we're having a little bit more control over your work life.
27:58 --> 28:16Jennifer Ligibel And then, you know, kind of on the negative side was sometimes oncologists take a lot of this home with them. It's hard to disengage when you've had a tough day and patients aren't doing well. So some of the negative impacts of their work on their family lives were some of the things that drove higher levels of burnout in that group.
28:16 --> 28:37Eric Winer Well, listen, it's, time to wrap up. It has been a total pleasure having you. I've been speaking with Jennifer Gabel, who is a professor of medicine at Harvard Medical School and leads the Zakim Center for Integrative Therapy and Healthy Living. Jennifer, total pleasure. Thanks so much for being here.
28:37 --> 28:38Jennifer Ligibel Thank you for having me.
28:38 --> 28:57Announcer If you have questions, the address addresses cancer answers@yale.edu, and past editions of the program are available in audio and written form at Yale Cancer center.org. We hope you'll join us next time to learn more about the fight against cancer funding for Yale Cancer answers is provided by smile o Cancer Hospital.

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Supporting Patient and Provider Well-Being March 15, 2026

Yale Cancer Center

visit: https://www.yalecancercenter.org

email: canceranswers@yale.edu

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Dr. Jennifer Ligibel

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