Point: InspireHealth: Engaging cancer patients in health

There is growing evidence that engaging patients in simple and inexpensive ways to support their own health can have a significant impact on outcomes in diseases such as cardiovascular disease, diabetes, and cancer. A growing body of evidence suggests that engaging cancer patients in their health (i.e., exercise, healthful nutrition, stress reduction, emotional support, etc.) can substantially improve quality of life, reduce the risk of recurrence, improve survival, and reduce overall health care costs. 

Integrated with standard cancer treatments, such programs empower patients to take ownership of their own health and play an active role in their treatment while simultaneously im­proving their survival and reducing the risk of cancer recurrence. The result is a higher quality of life with a reduced financial and social burden to patients, families, communities, and taxpayers. The greatest untapped resource in our health care system is our patients. 

Integrated with standard cancer treatment, emerging evidence suggests that support of health may be as important as standard cancer treatment in reducing risk of recurrence and im­proving survival. Some examples:

•    Exercise is associated with a 20% to 50% reduction in breast cancer recur­rence and death from the disease.[1]
•    Exercise is associated with a 50% to 60% reduction in cancer mortality in patients with colon cancer.[2,3]
•    In a large-scale randomized control trial, a low-fat diet combined with mo­dest weight loss was found to reduce breast cancer recurrence by 24%.[4]
•    An RCT found that a program of health engagement (exercise, meditation, vegetarian diet) may affect the progression of early, low-grade prostate cancer.[5]
•    Consumption of less meat, fat, re­fined grains, and sugar is associated with a substantial reduction (70%) in recurrence and increased survival in patients diagnosed with colon cancer.[6]

At InspireHealth, our physicians, nutritionists, exercise therapists, and counselors guide and empower cancer patients to integrate patient-centred health engagement into the excellent cancer treatment provided by the BC Cancer Agency. A not-for-profit society, InspireHealth is Canada’s leader in patient-centred programs that inspire, empower, and engage cancer patients in their own health.

The Samueli In-stitute (www.samueliinstitute.org), a leading US health care research organization, has identified InspireHealth as a leading example of patient-centred medicine and an optimal healing environment. The Samueli Institute recently received a $2.2 million research grant to study InspireHealth’s programs as a model of patient-centred medicine and their impact on patient empowerment, self-efficacy, sustain­ed healthful lifestyle change, and survival. 

We all become ill at some point in our lives—it is a shared human experience. When the specifics of the treatments prescribed by our doctor fade from our memory, what remains are our physician’s kind words of compassion, the warm support that helped us face our fear of the unknown, and their hand on our shoulder in assurance that everything was going to be okay—these are the moments that have the most meaning for us. Our relationship with our patients is as important as the treatments we prescribe. 

It is in this experience, this shared hu­man experience, where healing occurs—it is broader and as important as physical healing, although the two can be linked in important ways. It is this shared human experience that brings meaning to our work, to the illness experience, and to the lives of our patients; an experience through which we support healing by empowering and engaging patients in their health. 

Information alone is rarely sufficient to create lasting healthful life­style change. Most of us know that exercise and eating lots of fruits and vegetables is good for us and that smoking is not, but only 5% of cancer patients meet the minimal healthy lifestyle recommendations for healthful diet, exercise, and smoking in spite of the growing body of evidence of the importance of health engagement.[7] When we, as physicians, tell patients about the importance of eating healthfully, exercising, and smoking cessation, it rarely has the intended long-term effect. When we empower, engage, and inspire patients, lasting lifestyle changes can occur. 

A diagnosis of cancer, as challeng­ing as it is, provides a window of opportunity for significant lifestyle change. If supported in the right way, the fear associated with a cancer diagnosis can be transformed into inspired engagement in health. One of the most important shifts a patient can make in their healing journey—perhaps the most important shift—is to release patterns that limit their full love and support of themselves. 

Such shifts occur not as a result of information (although inspiring information is a helpful adjunct), but because of a healing shift to embrace and fully support their own health, happiness, and healing. This is an important frontier of medicine—to optimally engage our patients in their own health. At this frontier, we discover that the best way to facilitate healing in others (and thus, their engagement in their health) is to engage in our own healing and model health and well-being. 

Healing is a shared experience. When we are in a compassionate relationship with a patient and something shifts in their heart (e.g., forgiveness or acceptance), it is shifting in ours—it is a mutual experience that is healing for both of us. It is these moments that are the meaning of medicine, bringing meaning to our lives and to the lives of our patients. In this experience, we heal as we facilitate healing in others—we are not, in that moment, doctor and patient, we are co-creators of an experience that is healing and beneficial to both of us. In this mo­ment, as our hearts open, each of us experiences the shift that supports our own healing.

While physicians have responsibil­i­ty for treatment, we cannot take responsibility for someone else’s healing. The deeper we journey in our own healing, the better able we are to facilitate healing in others—not because we are taking responsibility for healing others, but because we are taking responsibility for our own healing. If we understand the paradoxical nature of our responsibility for healing, we are able to take full joyous responsibility for supporting our own health, happiness, and healing and release any sense of guilt or responsibility for our patient’s healing. In so doing, we are free to fully connect in compassion and human connection with our patients.

Cancer patients are at substantially higher risk than the general population for developing a second cancer and other illnesses including diabetes,8 cardiovascular disease,[8] obesity,[9] and osteoporosis.[10] Cancer patients common­ly report emotional distress, fa­tigue, reduced energy, and loss of stamina.[11] The incidence and impact of many of these health conditions can be reduced through healthful lifestyle changes, including exercise, healthful nutrition, weight management, and smoking cessation. Exercise and healthful eating reduce the risk of all chronic diseases (e.g., cancer, heart disease, diabetes, strokes, arthritis, etc.). 

During cancer treatment, regular mild-to-moderate exercise has been shown to improve well-being, in­crease energy, boost self-confidence, lessen anxiety and depression, stimulate im­mune system function, and improve appetite and sleep patterns.[12] Similarly, healthful foods also support our health and well-being. The ability for the body to heal is intimately related to how we nourish it. 

Along with the evidence that healthful lifestyle changes can substantially reduce the risk of recurrence and improve survival of people with cancer (and thus, substantially reduce overall health care costs), growing evidence exists that this integrative approach to supporting health during cancer treatment has substantial benefits in reducing overall costs in other important ways. Poorly adjusted cancer patients consume 130% more med­i­cal services, including 130% more hospital days, than well-adjusted patients. Even those who are fairly adjusted consume 80% more medical services than well-adjusted patients, including twice as many hospital days, as well-adjusted patients.[13]

This has substantial financial im­plications, since high distress levels are common among people living with cancer. In a recent study of over 3000 cancer patients throughout Canada, 37% of participants met the criteria for significant distress. Another study of 386 patients from 12 US medical centres found that 35% of patients had psychological distress and an even larger study, consisting of 4496 cancer patients, demonstrated a 35% overall rate of significant distress.[14] 

Programs to support the psycholo­gical and emotional well-being of cancer patients have been found to substantially decrease the average length of hospital stays by 78%, decrease hospitalization frequency by 67%, and reduce emergency room visits by 45%.[15] The potential cost-savings achieved by such a simple inexpensive intervention is significant. 

There is a strong positive association between the number of lifestyle recommendations being met and the quality of life of breast, prostate, colorectal, bladder, uterine, and skin cancer patients7 and these benefits have substantial health care cost implications. Cancer patients who experience fatigue report 50% more emergency room visits and 400% more visits to physicians and clinics.[16] Malnourished patients experience almost twice the average length of stay in hospital when compared to normally nourished equivalents.[17] 

Cancer patients who receive nutritional counseling are able to maintain their energy intake and reduce the incidence of fatigue.[18] Through simple approaches to support health—including healthful nutrition, exercise, and emotional and spiritual support—the incidence and severity of these symptoms (and their associated health care cost impact) can be significantly reduced. 

At InspireHealth, our eight physicians and other health professionals on staff provide a patient-centred environment that helps transform the fear of a cancer diagnosis into inspired engagement in health. Our programs, which include a 2-day LIFE program, healthful nutrition classes, exercise therapy classes, shared learning groups, yoga, meditation, and stress reduction classes, are all designed to empower and engage, often in a group setting in which patients can inspire and learn from each other. Our physicians, on salary through funding from MSP/PHSA, co-create an individualized health plan with the patient designed to optimally engage health. 

Unpublished, non-peer reviewed retrospective studies of all InspireHealth patients with stage 4 colon cancer (121 patients), stage 3B and 4 lung cancer (122 patients), and stage 4 breast cancer (119 patients) treated over an 8-year period at InspireHealth, found that attendance at InspireHealth was associated with significantly longer survival compared to BC cancer registry statistics. For example, 53% of InspireHealth inoperable lung cancer patients (i.e., stage 3B and 4) were alive 1 year after diagnosis, compared to just 20% or 23% of patients in the standard BC or SEER (US) survival curves for this disease during the same 8-year time period. At 3 years after dia­gnosis, 16% of InspireHealth pa­tients with inoperable lung cancer were still alive, compared to only 4% and 5% in the BC and SEER standard survival curve, respectively. 

These retrospective studies are not randomized control trials and therefore the results must be interpreted as an association rather than definitive cause/effect. For example, as InspireHealth patients are self selected, they may be more highly motivated or distinct in some other way compared to other BC cancer patients. However, the growing body of evidence in the research literature documenting the association between healthful lifestyle and im­prov­ed survival in cancer patients suggests that the results of these retrospective studies are promising. The up­coming Samueli Institute prospective study will further our understanding. 

With the growing body of evidence that health engagement plays an important role in a comprehensive cancer treatment strategy, the BC government has provided financial support for the expansion of InspireHealth throughout BC. InspireHealth Victoria opened in October 2011, to be followed by centres in Kelowna (September 2012), Prince George, and Abbotsford. 

In addition, a “virtual InspireHealth” has been created to provide programs to cancer patients and their families living in rural and remote BC communities. This visionary funding provided by the BC government marks the first time in the world that a government has provided funding to support access to integrative health programs for all cancer patients. 

We welcome anyone who would like to know more about InspireHealth and our programs to visit our website (www.inspirehealth.ca) or to come to InspireHealth for a visit to learn about our innovative programs in patient-centred medicine and engagement in health.

This article has been peer reviewed.

Counterpoint: InspireHealth: What's under the hood?

References

1.    Holmes MD, Chen WY, Feskanich D, et al. Physical activity and survival after breast cancer diagnosis. JAMA 2005;293:2479-2486.
2.    Meyerhardt JA, Giovannucci EL, Holmes MD, et al. Physical activity and survival after colorectal cancer diagnosis. J Clin Oncol 2006;24:3527-3534.
3.    Meyerhardt JA, Heseltine D, Niedzwiecki D, et al. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: Findings from CALGB 89803. J Clin Oncol 2006;24:3535-3541.
4.    Chlebowski RT, Blackburn GL, Thomson CA, et al. Dietary fat reduction and breast cancer outcome: Interim efficacy results from the Women’s Intervention Nutrition Study. J Natl Cancer Inst 2006;98:1767-1776.
5.    Ornish D, Weidner G, Fair WR, et al. Intensive lifestyle changes may affect the progression of prostate cancer. J Urol 2005;174:1065-1069.
6.    Meyerhardt JA, Niedzwiecki D, Hollis D, et al. Association of dietary patterns with cancer recurrence and survival in patients with stage III colon cancer. JAMA 2007;298:754-764.
7.    Blanchard CM, Courneya KS, Stein K. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: Results from the American Cancer Society’s SCS-II. J Clin Oncol 2008;26:2198-2204.
8.    Brown BW, Brauner C, Minnotte MC. Noncancer deaths in white adult cancer patients. J Natl Cancer Inst 1993;85:979-987.
9.    Rock CL, Demark-Wahnefried W. Nutrition and survival after the diagnosis of breast cancer: A review of the evidence. J Clin Oncol 2002;20:3302-3316.
10.    Schultz PN, Beck ML, Stava C, et al. Health profiles in 5836 long-term cancer survivors. Int J Cancer 2003;104:488-495.
11.    Broeckel JA, Jacobsen PB, Balducci L, et al. Quality of life after adjuvant che­motherapy for breast cancer. Breast Cancer Res Treat 2000;62:141-150.
12.    Cramp F, Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev 2008;16:CD006145.
13.    Browne GB, Arpin K, Corey P, et al. Individual correlates of health service utilization and the cost of poor adjustment to chronic illness. Med Care 1990;28:43-58.
14.    Carlson LE, Bultz BD. Efficacy and medical cost offset of psychosocial interventions in cancer care: Making the case for economic analyses. Psychooncology 2004;13:837-849.
15.    Sobel DS. The cost-effectiveness of mind-body medicine interventions. Prog Brain Res 2000;122:393-412.
16.    Ashbury FD, Findlay H, Reyholds B, et al. A Canadian survey of cancer patients’ experiences: are their needs being met? J Pain Symptom Manage 1998;16:298-306. 
17.    Smith P, Smith A, Toan B. Nutritional care cuts private-pay hospital days. J Parenter Enteral Nutr 1987;11:49.
18.    Radford K, Woods H, Lowe D, et al. A UK multi-centre pilot study of speech and swallowing outcomes following head and neck cancer. Clin Otolaryngol Allied Sci 2004;29:376-381.

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Dr Gunn is co-founder and CEO of InspireHealth. He supports the health of patients with cancer, and has a clinical faculty ap­pointment in the Department of Family Prac­tice at the University of British Columbia.