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Tania Jain, MBBS: Hello, everyone. This is Medscape InDiscussion podcast season two, episode two. I'm Tania Jain, your host with our special guest today, Dr Krisstina Gowin, who is an associate clinical professor at City of Hope Comprehensive Cancer Center serving as the director of education at Cherng Family Center for Integrative Oncology within the Departments of Supportive Care Medicine and Hematology and Transplant.
She focuses on myeloproliferative neoplasms (MPNs) but also has a passionate interest in integrative medicine. She's written a book called Living Well With Myeloproliferative Neoplasms, which was a philanthropic endeavor and is still available on Kindle for download. Dr Gowin, I've worked with her and she's probably one of the most passionate people I know supporting patients through their cancer journey.
Today, we'll talk with her on the topic of living well with MPNs. We derived that from the title of her book. Welcome, Dr Gowin.
Krisstina Gowin, DO: Thank you so much, Dr Jain. It is truly an honor to be on your podcast and the episode today. I love all the wonderful work you're doing for MPNs. I'm a huge fan.
Jain: Well, right back at you.
Gowin: Thank you.
Jain: We want to figure out a way into the discussion of integrative medicine. When we see patients with MPNs, one of the intriguing or specific things is that there are a lot of symptoms surrounding this diagnosis.
Could you tell us about what symptoms you encounter in clinic that you usually attribute to an underlying MPN?
Gowin: One of the unique things about this disease is the heterogeneous symptom burden, which was beautifully defined by Ruben Mesa, Robyn Scherber, and others and developed as a wonderful validated measure, the MPN Symptom Assessment Form. It has been incredibly practice-changing for us all because we realize that we're treating patients based on their symptoms and not just their blood counts and splenomegaly, right?
It is a new endpoint that we're using in clinical trial design. We're using it in National Comprehensive Cancer Network (NCCN) guidelines to direct when we potentially start a new therapy, a Janus kinase (JAK) inhibitor, etc. Symptoms are not only something that patients are experiencing but something for us, as clinicians, to use as a tool.
I think that's one of the most impressive movements forward for MPNs and for cancer care. That is, thinking about symptoms as an endpoint and quality of life as an endpoint. One of the biggest symptoms of MPNs is fatigue.
Eighty percent or more of patients with MPNs overall experience fatigue, and that's including polycythemia vera, essential thrombocythemia, and myelofibrosis. The debilitating fatigue can affect activities of daily living, ability to work, etc. It also affects many other things, such as difficulty concentrating and physiological symptoms like itching, abdominal discomfort, early satiety, bone pain, and weight loss. Pruritus is a tricky symptom; the itching is so difficult to control. The symptoms are heterogeneous, all over the map. There are a lot of psychosocial symptoms as well, like anxiety, depression, and sexual dysfunction.
When we're thinking about symptoms, even as MPN professionals, sometimes these get glossed over and are perhaps underaddressed. I always like to highlight the importance of those psychosocial sexual symptoms. It's a debilitating disease.
Again, it's hard as providers because we're focused on the blood counts and the size of the spleen. We have to take a step back and say, well, what's happening with you as a person and with your symptom burden?
Jain: I couldn't agree more. I think the spleen and the blood counts are objective metrics that we're all used to. I think work from Dr Mesa and Dr Scherber, going back almost a decade ago now, was instrumental in capturing the subjective metrics of the disease with the symptoms.
Tell me how these play into integrative medicine. You're cross-trained between oncology and integrative medicine. I have to admit when I heard that you were doing your fellowship in integrative medicine while doing your oncology fellowship, it was the first time I heard about the field.
So, pardon my ignorance, but I was very intrigued and excited. Can you tell us about integrative medicine and when and who should reach out to you for your expertise in this space?
Gowin: You're not alone. I would say that the community is starting to learn about integrative medicine now because it's coming to fruition in mainstream medicine. That's happened in the last 5 or 10 years or so. It's new, but it's up and coming and it's becoming very popular. We can hardly keep up with the demand, which is a wonderful problem to have.
I'd like to start with the definition of integrative oncology. This definition is evidence-based, it came from the Society of Integrative Oncology, where they convened an expert panel and said, okay, let's sit down and let's nail this down. How do we describe integrative oncology? What we're talking about here is not just integrative medicine, but integrative medicine as it applies to cancer patients and in these MPNs. Integrative oncology is defined as a patient-centered, evidence-informed mind-body practice, natural products and lifestyle modifications from different traditions alongside conventional cancer treatments. And that's truly what makes integrative oncology different from, say, complementary or alternative medicine. It's truly alongside the best of what we have in true mainstream cancer care.
Integrative oncology aims to optimize health. I'm going to talk a little bit about how we can improve quality of life and clinical outcomes across cancer and, I love this part, this is my favorite, to empower people to prevent cancer and become active participants before, during, and beyond cancer treatment in their survivorship phase.
Patients always come to me and say, what can I do? I'm taking my medicine, I'm showing up, I'm doing my MPN symptom burden, but I want to do more. What can I do? I want to be the driver of my bus. That's where I think the power of integrative oncology shines. Some things are tangible that can be led by patients and caregivers.
Getting to your question, Dr Jain, about when to engage integrative oncology practitioners. I think the answer is, when don't you? It's so incredibly important, particularly in MPNs. I think about how much it can help in terms of lifestyle, stress management, and symptom management.
I think this group of patients, many others as well, but MPNs uniquely, can benefit from integrative oncology. We have to certainly jump off into thinking about just the pathophysiology of the disease, right? We're all worried about thrombotic complications.
Even in our NCCN guidelines, we're talking about modifying the cardiovascular risk factors. Those are some of the hard endpoints and recommendations in our algorithm. How do you do that? It's through lifestyle, nutrition, exercise, stress reduction. We need to be incorporating integrative medicine from day one, from the very beginning, from diagnosis. I think the answer is to engage the team early on. The team is different depending on where you are. In every academic center and community center, there are different resources around you as a physician. I think part of our work is to understand what those resources are. What kind of referrals are possible?
With that information, start to create some of those workflows. For instance, it is wonderful to have an integrative oncology center, but if you do not, maybe there's a nutritionist or a rehab person, etc. I recommend trying to work through all of the different modalities that potentially can be helpful and then creating referral patterns.
Jain: That's beautiful. You're prompting me to ask a question I get so often in my clinic from patients. What can I do in my diet or what should I do in my diet to mitigate some of the risks from MPNs?
I'm sure that's a question that's asked in many clinics, not just MPN clinics. What guidance do you usually provide when you get asked this question?
Gowin: Yeah, it's a great question. You're exactly right that it's a uniform question, in that it's not an MPN patient-specific question. I get this question when I see breast cancer patients or prostate cancer patients, too. Some of our data is borrowed from cardiovascular disease research, where we really look at the impacts on inflammation. Through all these modalities in integrative oncology, but in particular, with nutrition, our goal is to modulate inflammation. Inflammation, as you know, is one of the hallmarks of what makes a cancer cell a cancer cell.
In that wonderful paper by Hanahan and Weinberg, looking at all the hallmarks — tumor-promoting inflammation is there — how do we impact that? Well, lifestyle and nutrition.
The Mediterranean diet is the best studied and shows the most potent impacts on inflammation and, importantly for the MPN community, it impacts cardiovascular health such as lower risk of cardiovascular events like heart attacks. Cardiovascular death and overall survival are impacted as well.
In the PREDIMED study with over 7000 patients, they did a meta-analysis looking at the incidence of breast cancer, and those who were eating the highest quartiles of this Mediterranean-like foods had a lower incidence of breast cancer. That's not a randomized controlled trial, but it's certainly a provocative meta-analysis.
I think the Mediterranean diet is really the way to go. What is included in that? There are lots of fruits and non-starchy veggies, lots of color, lots of omega 3 fatty acids, and trying to be sure that you're not getting any processed foods, right?
There are more and more data coming out about processed foods and their impact on quality of life, brain function, even telomeres. I always tell patients to grocery shop on the perimeter. The inner aisles of the grocery stores are where all the evil comes from. Stay on the perimeter.
So, eating whole foods with lots of fiber, lots of color is important, and that's the recommendation we're looking at that impacts in MPNs. Dr Angela Fleischman from UC Irvine has done some interesting work looking at the Mediterranean diet in MPN patients and showing that, at least in small studies, it's impacting inflammation, impacting cytokines, and also our microbiome, which is so important. Our gut microbiome is our second brain; it's another immune system, and we're showing more and more how important the microbiome is for cancer outcomes. With a Mediterranean diet, there's enhanced diversity and that's what we're always looking for in microbiome research: diversity, diversity, diversity. For all those reasons, I recommend the Mediterranean diet.
Jain: That's beautifully answered. The role of inflammation probably spans beyond MPNs into a lot of diseases and diagnoses within and outside of oncology. I'll take this opportunity to have you answer another question that I stumbled upon in the clinic and struggle to answer. What is the role of exercise?
Again, it is something patients want to do, and I wonder what a good exercise regimen or exercise routine is for wellness in general and specific to MPNs. I used to hear you talk about tai chi a lot during fellowship. Maybe that'll be a part of the answer. I'm excited to hear your thoughts.
Gowin: It's part of that lifestyle prescription, and exercise is essential. It influences quality of life, inflammation, and disease outcomes. We see in large datasets from breast cancer, prostate cancer, and colon cancer. We just published a review paper in Mayo Clinic Proceedings looking at lifestyle and cancer. We had to go back and forth with the editors because our tables were so long, from the amount of data for lifestyle and cancer. So, why don't we have a prescription pad to write an exercise prescription with our aromatase inhibitor for breast cancer? We need to, it is medicine. Exercise is medicine.
To back up for a minute, for the MPN patient population, the datasets are limited. There is not a lot of research yet, certainly nothing as robust as in breast cancer and colon and prostate cancer. We have to borrow from the knowledge of what's happening in other cancers. I'll put a call out for research, we need more data in MPNs.
Anecdotally, I have seen the benefit in clinic. I can also speak to some of the smaller studies. There was a feasibility study of about 50 MPN patients looking at aerobic and resistance training, and it was feasible to do these kinds of interventions in MPN patients. And we did a yoga trial looking at the impact of yoga.
This was all remotely delivered on MPN symptom burden, as well as some of the markers of inflammation. We did see that there was a statistically significant reduction in tumor necrosis factor-alpha in those that were participating in only 10 minutes of yoga a week, if you can believe that.
Although the sample size was quite small, around 40 patients, some effect sizes were looking at sleep and depression and anxiety. We need more research in the MPN population, but my recommendations are certainly to undertake exercise regimen. We can use recommendations from the American Cancer Society, which is 150 minutes of moderate intensity of exercise per week, if patients can tolerate it, with a mix of aerobic resistance. As you mentioned above, I love meditative movements such as yoga and tai chi. I always try to put that into the regimen as well. I recommend all three: aerobic, resistance, and meditative movement.
I'll take a couple of moments on tai chi. Tai chi and yoga are some of the most evidence-based interventions in integrative oncology, overall. There's quite a lot of data — breast cancer, in particular, has huge amounts of data showing the impacts on quality of life and symptom control and even disease outcomes.
And it's part of the guidelines that we have now. There are some guidelines that we've developed within the Society of Integrative Oncology for symptom management. We've done this now for symptom management of pain, anxiety, depression, and then most recently of fatigue. Those are all published within JCO, and they are endorsed by the American Society of Clinical Oncology (ASCO).
Yoga and tai chi are both in the guidelines for pain, anxiety, depression, and fatigue. They've made it into all of the guidelines. That is evidence-based and again, endorsed by ASCO. Trying to find community resources to get patients involved is wonderful. There are so many online resources now that you don't even have to go to the gym, especially in the era of COVID. We had to establish new modalities to deliver these and so it's accessible.
Jain: That's beautiful and certainly something that goes beyond MPNs or beyond even any diagnosis. I'm going to pivot a little bit towards your book. I think I remember there is a section on complementary therapies in addition to JAK2 inhibitors or other strategies that we think about.
Tell us a little bit about how you approach that in clinic. Beyond JAK2 inhibitors, what can we do?
Gowin: From a pharmacologic standpoint, I am very cautious and conservative when it comes to supplementation. Curcumin, for example, is a derivative from turmeric, the active ingredient from turmeric, and it has been widely studied for impacts on inflammation, actually as a natural JAK-STAT inhibitor. But we're very careful because there have been no studies really beyond mouse models, looking at the safety and efficacy of combination therapy with JAK inhibitors as well as curcumin.
The first premise of medicine is to do no harm. And I adhere to that. But particularly with supplements, I'm very careful. From a complementary approach, what I like to do is look at the guidelines. For example, I mentioned the ASCO guidelines. I would look at the symptom and say, what's the best evidence base for a complementary modality for this particular symptom.
For example, let's talk about cancer-related pain. We know acupuncture has a good amount of evidence for the management of pain. And so, consider acupuncture if they're open to it. Reflexology is also in the guidelines. If they're afraid of needles, you can do acupressure. Massage has data for improving cancer-related pain, particularly in breast cancer.
Those are nonpharmacologic interventions that have a very low risk, but potentially a very high yield in managing symptoms. We talked about yoga for physical activity. Yoga is in the pain guidelines too, as well as guided imagery with progressive muscle relaxation. All these modalities have enough evidence to be recommended to try for cancer-related pain.
We also look at procedural pain and put that in a separate category. We looked at the data for that, and hypnosis can be helpful for, say, bone marrow biopsies. Acupressure, acupuncture, and music therapy can be helpful for that kind of associated pain. For anxiety and depression, there's a whole different kind of treatment.
I think there is a good set of guidelines so that you can follow the algorithm, and nice publications within JCO last year about similar interventions such as mindfulness, yoga, relaxation, music therapy, tai chi, and qigong. For me, I start with those that have the most evidence for them and have the least risk for harm.
When it comes to supplements, American ginseng did make it into the guidelines for fatigue. The quality of evidence is low, and the strength of the recommendation is conditional, meaning that you can consider trying it. I have tried American ginseng with some patients, and it has made an impact. I see this especially with a patient who is refractory to some of the other modalities. They're already doing the things. They're adjusting their diet, exercising, doing their mindfulness activities, they've tried acupuncture, and they're just really refractory. That's the kind of patient that I'll have the conversation around American ginseng.
I would say that there's no one-size-fits-all modality. I listen to patients and say, what's meaningful for you and your culture? There are so many folks who come from different areas around the world that already in their mind have what they think is going to be the most potent and beneficial strategy for them.
I like to evaluate that, turn that stone over and say, is there evidence? Can we support that? Because if the patients are already interested in that modality, it is more likely to be effective.
Jain: Wow, that's beautiful. I wish I could continue hearing about this because everything that you've told us today or spoken about today is a learning point. I think all of us who are listening will be implementing it in our clinics easily and quickly tomorrow or even today.
Do you have any last words, Dr Gowin?
Gowin: Some of us are undergoing burnout, or having our own health issues, and so as we practice this kind of counseling in clinic, it's our own reminder to do this for ourselves.
Jain: That is beautifully put, and I agree a beautiful reminder for all of us. Well, with that, we're going to end. I'm sure I speak for all of us in that we are very, very thankful to Dr Gowin for sharing her expertise and thoughts on this critical, delicate, and important topic that we encounter on a frequent, maybe daily basis in our MPN clinics. We're going to come back with our episode three. Thank you again, Dr Gowin.
Listen to additional seasons of this podcast.
Resources
Comprehensively Understanding Fatigue in Patients With Myeloproliferative Neoplasms
The NUTRIENT Trial (NUTRitional Intervention among myEloproliferative Neoplasms): Feasibility Phase
Lifestyle Factors and Cancer: A Narrative Review
American Cancer Society Guideline for Diet and Physical Activity for Cancer Prevention
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Cite this: Diet, Exercise, and Myelofibrosis: A Holistic Approach - Medscape - Mar 06, 2025.
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