Chapter 11: Research Projects at MD Anderson, the First Focus on Integrative Methods

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Chapter 11: Research Projects at MD Anderson, the First Focus on Integrative Methods

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Dr. Cohen notes that the first phase of his research conducted when he arrived at MD Anderson in 1997, focused on "conventional psychodynamic studies" such as his study of management of presurgical stress in breast and prostate cancer patients. He notes that a turning point came when he met Alejandro Chaoul, a graduate student at Rice University who was volunteering at MD Anderson, and initiated a study of the effects of yoga on post-surgical lymphoma patients (published in Cancer). He explains the focus of the study, the results, and how it evolved. Next, Dr. Cohen talks about the life quality issues of primary concern to cancer patients, including fatigue, pain, peripheral neuropathy, and sleep disturbances.

Identifier

CohenL_03_20160824_C11

Publication Date

7-24-2016

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The Interview Subject's Story - The Researcher; The Researcher; Understanding Cancer, the History of Science, Cancer Research; Professional Path; Overview; Definitions, Explanations, Translations; Research, Care, and Education; Research; Patients; Patients, Treatment, Survivors; Cancer and Disease

Transcript

T. A. Rosolowski, PhD:

OK, well then let's... Let me put the identifier on right now. So we are recording. It is one minute after 9:00, and I'm Tacey Ann Rosolowski, and today I am sitting in the office Dr. Lorenzo Cohen for our third interview session together. It is August 24th, 2016. So thanks again for making the time. And as the listener can tell, we were strategizing and talking a bit before the recorder went on. (laughter) So the big, outstanding area, as I -- as, you know, we mentioned -- was really the evolution of your research beyond those early days when you first came to MD Anderson. So if you want to tell me that story, that would be great.

Lorenzo Cohen, PhD:

Sure. So some of the first projects that I got engaged in what you would -- could call conventional psycho-oncology studies, examining ways of delivering brief cognitive behavioral therapy within conventional medical procedures, like we had discussed pre-surgical stress management for guys with prostate cancer, and we tried to embark on doing a similar study in breast cancer. And I can't remember the exact date, but Alejandro Chaoul, probably starting in 1998 or "˜9, like really early, when the Place of Wellness, which then became the Integrated Medicine Center, opened its doors, and Alejandro was at that point a graduate student at Rice University, and he was volunteering at MD Anderson, providing mind/body practices, and specifically... The volume's good?

T. A. Rosolowski, PhD:

Yeah, we're good.

Lorenzo Cohen, PhD:

Specifically Tibetan meditations and what was called Tibetan yoga to our cancer patients as -- again, as a volunteer. Place of Wellness back then, as we had discussed, was really relying on volunteers, because there was no budget, really, to support the programming, per se, until it expanded in 2002. And so he came -- Laura Baynham Fletcher, who at that point was the -- not the director of the program but actually the kind of, like, program administrator, said, "You know, you may want to meet with Lorenzo, because he's interested in doing research in this area. And so I met with Alejandro, and he didn't know anything about research. I'd never even heard of Tibetan yoga. I'd obviously heard about yoga, (laughter) and heard a lot about Tibetan meditation, but not these ancient movement-based practices coming from the Tibetan Bön tradition, which was the religious tradition in Tibet prior to the arrival of Buddhism. Some, potentially inappropriately, call it sort of shamanistic practices that existed, and it's often said pejoratively because, you know, Buddhism came in and wiped out, physically and harshly, the religions that existed in Tibet at that time, so --

T. A. Rosolowski, PhD:

I didn't realize that.

Lorenzo Cohen, PhD:

-- we think of Buddhism as this peaceful, and it's, no, they came in and they slaughtered these monks who were --

T. A. Rosolowski, PhD:

Wow.

Lorenzo Cohen, PhD:

-- or they converted them, so to speak. You know, I'm simplifying, obviously, because --

T. A. Rosolowski, PhD:

Converted at knifepoint, right. (laughter)

Lorenzo Cohen, PhD:

Yeah, exactly. So anyway, the Bön tradition kind of still exists a little bit, and some practice it, and everyone's friends again, but this is pre. This is, like, pre-Buddhism. So Alejandro is this religious -- PhD religious scholar at Rice University, studying these ancient texts, and deeply engaged personally in the practice, and in teaching, and in teaching at MD Anderson. So we embarked on conducting a study of yoga for actually lymphoma patients, because at that time the -- I don't think she actually had a big title. Dr. Alma Rodriguez [oral history interview], who's a lymphoma physician, was going to Alejandro's center outside of, you know, her wearing her work hat, and so he said, "Well, have you ever heard of, you know, Alma Rodriguez? We could work with lymphoma patients. And I was like, "No. I'm not sure I want to work with lymphoma patients. Not that I have anything against lymphoma patients, but, you know, they're not -- it -- they're going to be harder to recruit, the numbers are smaller, etc., etc. So anyway, we were successful in conducting a study of what we called Tibetan yoga, movement-based practices from this Tibetan Bön tradition that incorporate breathing, visualizations, and movements synchronized with unique breath work. Published it in 2004, I think it was, in the Journal of Cancer, and at that time, surprisingly to me, it was actually the first study of -- the first randomized trial of yoga in any cancer population. There's been other studies of yoga in cancer, but none were like these formal RCTs where, you know, patients were randomized, and half got it, half didn't, and...

T. A. Rosolowski, PhD:

So how did you set up the study? When were the patients instructed in this tradition of yoga? What were your goals?

Lorenzo Cohen, PhD:

So we kind of -- you know, we'd never done this before. I'd never done yoga research before. So we kind of took all comers with lymphoma who were either undergoing active treatment or within the first 12 months having completed treatments, and they're still kind of experiencing some of the residual side effects. And really, you know, in this first study, interested in aspects of quality of life, so it was all subjective, as we'd call it, paper-and-pencil-validated measures of depression and anxiety and sleep and physical functioning and spirituality and that kind of thing. And this was kind of new for, obviously, for the lymphoma group, but, you know, everyone was very supportive and on board. There was no, let's say, challenges in running the study, except for getting patients, because they were sick, they didn't want to do it, they tended to be older. Not that any of that's... I mean, the main issue was, you know, compliance once they were in the study, and dropping out, and... But we ended up getting I think it was specifically 39 patients, and it seems like such a small number, so... It was, and it was a small pilot study. And found the most -- the strongest finding was that we saw benefits for sleep quality. So the patients reported better -- well, the term is actually that they had reduced sleep disturbances, so they had better overall sleep quality, they slept longer, they fell asleep faster, which is called sleep latency. So from the time you go to bed to the time you actually fall asleep -- which, of course, is an important outcome -- as well as reporting that they were taking fewer sleep medications, which, of course, all told, is a great outcome. It received a lot of publicity, partly because it was the first study of its kind, and had this very strong finding, manipulating or modifying an outcome that is actually quite problematic for cancer patients, this issue of sleep disturbances, that can persist actually for quite a long time after diagnosis. I was just looking to get the exact...

T. A. Rosolowski, PhD:

Is there a list of big issues, quality of life issues for cancer patients? I mean, I sort of imagine there would be this amazing, long list of them, but are there some key problems that are of real concern?

Lorenzo Cohen, PhD:

Yeah, I mean... Well, and it depends on when in the trajectory, but all these issues... Well, nausea and vomiting never becomes chronic. It's always an acute issue, meaning that a year after treatment you're not walking around with this constant nausea. But during, you know, treatment and recovery, it is one of the big ones, nausea and vomiting. Fatigue is a big issue during treatment, and in a subset of patients can become chronic, meaning forever. Pain, similarly, of course, during treatment, surgery, recovery, etc., radiation, can become -- is an acute problem that for many becomes chronic. We've just started a study for acupuncture to treat chronic post-mastectomy pain, so these are women who a year later they're still experiencing pain, and nothing seems to really help them.

T. A. Rosolowski, PhD:

Is this what -- I've heard the term "engraved pain,in that, you know, the neural pathways become so accustomed to the pain that it just stays all the time. Is that...?

Lorenzo Cohen, PhD:

Yeah, I mean, so it could be that, or it could be this concept of a phantom, you know, particularly when you're dealing with a mastectomy. And so there's actual neural reorganization that helps to explain why people, like, who lose a limb say they are experiencing pain when there is no limb there. Could be something similar with breasts, but also just this... And the reason people are experiencing the phantom is because of this established relationship that happened at the time of the trauma, the dual path gateway theory of pain which was coined and discovered by Ron Melzak from McGill University, who is the mentor of a former colleague of mine that I did pain research with when I was up in Toronto, trying to break that relationship. So pain, that's another one mentioned, fatigue. A kind of pain, but it's not really pain, per se, is peripheral neuropathy. This is something that is really problematic in a very large percentage of patients who get chemotherapy, and it's actual damage of the nerves in the fingers and in the feet, hands and feet, which, again, can be permanent, and can be so debilitating that people have a hard time dressing themselves and walking, even. And we have three areas of research trying to help with that chronic condition: acupuncture, massage, and the work of Sarah Prinsloo, which is neural feedback, so actually changing the way the brain is functioning and interpreting these signals from the periphery. Sleep disturbances in particular, and after this initial research with Alejandro we expanded it -- we actually did a small study in breasts, which was too small to really interpret too much, but good enough to get a large R01, that we've just resubmitted the paper to JCO, showing benefits for sleep, but not quite as strong as we wanted. What's the most compelling thing about this larger study, which is in over 200 breast cancer patients, three-armed clinical trial -- so we had an active control group that learned some stretching exercises -- is that the patients who were practicing their yoga two times a week or more had substantially better outcomes than the control group, as well as the stretching group, and as well as their counterparts in the yoga group, who weren't practicing two times a week or more. So, you know, that's sort of stating the obvious, but, you know, it's a challenge of these sort of self-delivered interventions, because it's not as easy as taking a pill. So, you know, everyone knows if you don't take your antibiotics the bacterial infection will not go away, so the same kind of thing: if you have a sleep disturbance, and we know yoga's going to help you, if you don't do the yoga you will still have your sleep disturbance. So it, you know, again, is a message that everyone's grandmother could tell you, but it's kind of good to get it out there in the medical community, and we're hopeful that it will get accepted in JCO and continue to push this message out.

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Chapter 11: Research Projects at MD Anderson, the First Focus on Integrative Methods

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