Integrative Medicine in Interventional Oncology: A Virtuous Alliance

This review aimed to identify the potential role of integrative medicine in interventional oncology. The music therapy; stress management techniques; guided imagery, including virtual reality; clinical hypnosis; and digital sedation may all be efficient on anxiety and pain during procedures performed in interventional oncology. Beyond pharmacological sedation, the implementation of integrative medicine to interventional oncology may, therefore, improve the support and care of cancer patients, which may further create a virtuous alliance.


Introduction
Interventional oncology (IO) offers minimally invasive diagnostic and therapeutic procedures to manage certain cancer-related problems [1,2]. These image-guided procedures include biopsies and treatments such as embolization, percutaneous ablation, or cementoplasty, allowing local control or symptom relief [2][3][4][5]. They are mainly performed under local anesthesia by interventional radiologists (IR) but they may cause anxiety and pain to patients [6][7][8][9]. Therefore, additional management should be implemented in concert to better take into account the patient s well-being [9], including integrative medicine (IM).
By considering the whole person and their lifestyle, IM promotes the therapeutic relationship between practitioners and the patient [10]. IM techniques can be implemented relatively easily before, during, and after all IO procedures to manage anxiety and pain leading to improvement in both the quality of life and the well-being of cancer patients [6]. The objectives of this review are to describe the rationale of IM and to detail the techniques that can be used in IO. A MEDLINE/PubMed literature search was performed using keywords such as "interventional oncology" and "integrative medicine". The articles published between January 2000 and December 2019 were selected based on their relevance, as well as cited references.

Definition of Integrative Medicine
The aim of Integrative medicine (IM) is to improve the patient s health by combining some alternative medicine (AM) with traditional conventional medical therapies [11]. IM considers the patient s unique conditions, needs, and circumstances [12]. Therefore, IM places the patient at the center of a personalized therapy strategy. IM differs from AM, which refers only to therapies used instead of conventional therapies [12]. Unlike AM, only therapies that have high-quality scientific evidence of safety and efficacy such as meditation, music therapy, and clinical hypnosis are combined with medical treatments in IM [11,13].
Due to the great needs of cancer patients, IM was thoroughly evaluated in this population [13]. To protect patients from potentially harmful treatments, and to manage symptoms and side effects before, during, or after treatment, some guidelines exist for the use of IM, such as in breast carcinoma [12,13]. A dedicated IM program helps to provide effective and appropriate care [14].
IM goes beyond conventional treatments to address all causes of discomfort, including anxiety and pain, both of which affect well-being [15]. Therefore, to address the full range of biological, behavioral, psychosocial, and environmental influences that can affect a person s care, immediate needs and complex interactions between all influences are taken into account [16]. Everything that can influence health, well-being, and illness are considered, including body, mind, spirit, and community. Prevention or healthy behaviors are promoted. The development of skills that patients can use throughout their lives is encouraged. Less invasive procedures, which may include IO procedures, are preferred wherever possible and take full advantage of the effectiveness of techniques developed in IM [14].

Implementation in Interventional Oncology
The IR must provide each patient with adequate analgesia and sedation to manage anxiety and pain, and potentially amnesia, from the procedures they perform [8,9,17]. Besides minimizing the risk of complications, they must improve patient comfort before, during, and after the intervention. An uncomfortable and unfamiliar environment or the fear of loss of control may increase stress [9]. Although anesthesiologists are better trained to achieve these goals, they are not available to assist with all IO procedures. As sedation poses significant risks to patients [9], alternative techniques developed in IM can be used in combination with minimally invasive image-guided procedures developed in IO to alleviate anxiety and pain while ensuring better diagnosis and results.

Relational Commitment
As anxiety is often correlated with the patient's relationship with professionals, the elimination of negative language from dialogue, replaced by positive or neutral language, may create self-confidence and relaxation [9,18,19]. As IM requires ongoing education and training to ensure patients receive multimodal treatment based on the unique needs of each patient, a dedicated consultation before any procedure can help relieve symptoms associated with cancer and also identify the IM technique that best suits the patient's needs. Interactive wall projections in the IO waiting room can also be helpful. Having an IM service in a hospital system will certainly help to ensure coordinated patient care and to optimize the patient path to and from the operating rooms [14]. A specific data collection and analysis program must also be developed to obtain the mandatory high-quality scientific evidence of safety and efficacy, integrating new technologies such as artificial intelligence (AI). For example, to further strengthen the partnership between patients and practitioners as well as to assess the additional value of IM to IO, patients, family members, and staff could regularly use smartphone health apps to collect levels of self-reported well-being, pain, and anxiety, or satisfaction.

Naturopathic Medicine
Naturopathic medicine encourages the inherent process of self-healing [14]. Nutrition, herbal medicine, homeopathy, lifestyle counseling, and mind-body medicine are promoted [14]. While many of these techniques are beyond the scope of this review, nutrition may be interesting to evaluate in IO. For example, curcumin has been used for millennia because it improves immunity against cancer. Interestingly, experimental studies in mice have demonstrated significant inhibition of tumor growth after combining curcumin with percutaneous cryoablation [20]. These results are supported by several preclinical and clinical studies demonstrating that percutaneous ablations combined with appropriate immunomodulators can induce a therapeutically effective systemic anti-tumor immune response [21]. However, as some supplements or herbs can interfere with certain medications by altering their absorption, metabolism, or excretion, all treatment plans must be discussed to ensure that all practitioners are aware of this medication.

Music Therapy
Anxiety and pain can be mitigated by auditory inputs [22]. Music therapy has relaxing and distracting effects. Pain and auditory pathways have been suggested to inhibit each other [22]. Music therapy can be passive when the patient only listens to music, or active when the patient is creating live music. Significant improvement in anxiety, drowsiness, depression, nausea, fatigue, pain, and shortness of breath were demonstrated in a clinical study [23]. Music therapy decreases the need for sedation and pain relievers [22,24].

Meditation and Stress Management Techniques
Meditation, including yoga, qi gong, and tai chi chuan, aims to promote calm and concentration [12]. It allows participants to bring mental processes under greater voluntary control [25]. However, in addition to specific training, it requires a quiet location to limit distractions of concentration and attention. It also often needs a specific and comfortable posture that can be a challenge in the operating room.
Stress management techniques are very low-risk interventions inducing a parasympathetic response [14,[26][27][28]. They are only contraindicated in patients with psychotic disorders. Progressive muscle relaxation, autogenic training, deep breathing, biofeedback, and guided imagery decrease anxiety [29]. These techniques must be taught beforehand to induce a relaxation response during interventions through stress management programs.
Among these techniques, guided imagery uses thoughts and imagination towards specific scenes to guide patients to achieve a specific objective [30]. Guided imagery reduces anxiety and pain, and can improve a person s overall sense of well-being [31]. Face-to-face individual sessions are recommended to adapt the script to the patient s life circumstances, although recordings are easier to implement and use. Virtual reality (VR) technology has been studied to facilitate access to this technique [32][33][34][35][36][37][38]. VR further isolates a patient from their direct environment by distracting their attention. Randomized studies have demonstrated an effect on the perception of anxiety and pain [39]. For example, VR reduces pain during burns or punctures [40].

Clinical Hypnosis
The principle of clinical hypnosis in IO is to create a modified state of consciousness of sensory elements. It is based on verbal suggestions made by a professional. The first objective is to relax the body and shift attention to a narrow range of objects or ideas. Secondly, the practitioner leads the patient to a dissociative state [41][42][43][44][45][46]. This trance state allows the patient to focus without distraction on specific feelings, thoughts, images, sensations, or behaviors [12].
Studies have shown that the effects of clinical hypnosis are similar to intravenous sedation [41], helping to reduce the need for medication during procedures [47][48][49] as well as costs [50]. Unfortunately, clinical hypnosis has had limited development in IO, which has been linked to professionals exposure to X-rays [51], as well as a lack of training and limited standardization of the technique [52][53][54].

Digital Sedation
Beyond using VR as a distraction tool and performing clinical hypnosis remotely using headphones, digital sedation (DS) has been developed [9]. To produce a dissociative state similar to clinical hypnosis without direct interaction with a professional, DS captures all of the patient's attention by combining visual but also auditory sensations and verbal suggestions using a VR mask and headphones ( Figure 1A) [55]. DS uses a multidimensional immersive VR technology, which is much more effective than traditional distraction methods like video games or movies [56,57]. Following a script, DS suggests different sensations that patients sometimes find it difficult to imagine through verbal suggestions ( Figure 1B) [52,58,59]. Interventional oncology operating rooms are often first designed to incorporate functions supporting highly advanced medical care, such as cone beam computed tomography, before considering patient well-being. (D) Future facilities using mobile robotics-assisted medical systems will allow to easily perform in-suite integrative medicine techniques and to improve the patient pathway to and from the operative rooms, limiting additional stress and anxiety (Discovery cone beam computed tomography system, courtesy of General Electric Healthcare, Buc, France). Therefore, interesting standardized clinical applications can be developed for use during procedures performed in IO to limit anxiety and pain, similarly to clinical hypnosis or guided imagery, while limiting radiation exposure to staff, not only during the procedure but also after that [60]. In a study comparing DS with sedation in endoscopic urological surgeries [61], DS was more effective in terms of patient and anesthesiologist satisfaction. Although evidence of the effectiveness of DS in reducing anxiety and pain is accumulating [39], further evaluation is still necessary.

Toward Designing New Interventional Oncology Facilities
Although going beyond the scope of this review, architecture, art, and design can inspire well-being through the creation of a human-centered environment. Medical buildings or medical systems are often first designed to incorporate functions that physically support very advanced medical care, such as those developed in IO [62] ( Figure 1C). However, they are rarely designed to create self-confidence and relaxation. Exploring the relationship between the architecture or design of healing facilities and a healing environment that promotes IM must be done in the future development of health care facilities. IO suites and medical systems, such as X-rays, computed tomography scan, or magnetic resonance imaging used to guide IO procedures, should be designed to easily perform IM techniques and to improve the patient s path to and from operating rooms, limiting additional stress and anxiety [62] ( Figure 1D). These health facilities must avoid noise, integrate indoor and outdoor spaces as well as the demands of daily life, and combine sophisticated technologies, such as VR, and traditional architectural techniques to remain sustainable and affordable, and to create a new ekistic reality fully integrated into its existing regulations and environmental and historical landmarks [63,64].

Conclusions
IM may be helpful to reduce anxiety and pain during IO procedures. New technologies such as VR and AI can be used to design wellness-focused digitization throughout the patient journey inside and outside of hospitals. As both IO and IM work together to improve well-being, the partnership between IO and IM may further create a virtuous alliance, allowing improved support and care of cancer patients throughout the disease. Funding: This research was partially funded by Fondation du Roi Baudouin, Belgium.

Conflicts of Interest:
The authors declare no conflict of interest.