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Special Communication  |   June 2019
Integrating Osteopathic Philosophy in Cancer Care
Author Notes
  • From the Center for Cancer Research at the National Institutes of Health in Bethesda, Maryland (Drs Brown and Martin); Rutgers Robert Wood Johnson Medical School in Piscataway, New Jersey (Dr Brown); and the University of Pittsburgh Medical Center Pinnacle Community Campus in Harrisburg, Pennsylvania (Drs Martin and Carman). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Zachary J. Brown, DO, Rutgers Robert Wood Johnson Medical School, PO BOX 19, New Brunswick, NJ 08901-0019. Email: zb109@rwjms.rutgers.edu
     
Article Information
Being a DO
Special Communication   |   June 2019
Integrating Osteopathic Philosophy in Cancer Care
The Journal of the American Osteopathic Association, June 2019, Vol. 119, 391-394. doi:https://doi.org/10.7556/jaoa.2019.068
The Journal of the American Osteopathic Association, June 2019, Vol. 119, 391-394. doi:https://doi.org/10.7556/jaoa.2019.068
Web of Science® Times Cited: 1
Abstract

Recent breakthroughs in the fields of genomics and biology have resulted in a better understanding of diseases and their underlying biology. New targeted and immune-based therapies take advantage of these new discoveries to treat the patient individually. This scientific revolution toward personalized medicine reflects osteopathic medicine's emphasis on patient-centered care and its tenets, which go against the “one-size-fits-all” approach. The authors discuss the importance of applying osteopathic philosophy to the delivery of patient-directed cancer care revolutionized by scientific advances.

The osteopathic medical profession has continued to evolve since 1892, when Andrew Taylor Still, MD, DO, rebelled against the “one-size-fits-all” medical system. Today, osteopathic physicians deliver highly specialized care while still holding true to the core of osteopathic philosophy that emphasizes patient-centered care over symptom-centered care. Still understood that managing symptoms does not cure disease; rather, musculoskeletal manifestations of disease mandate further investigation.1 In oncology, scientific breakthroughs, such as CRISPR-Cas9 (Clustered Regularly Interspaced Short Palindromic Repeat; CRISPR associated protein 9), have led to a better understanding of the underlying biology that governs cancer progression and response to treatment. This scientific revolution, which has advanced the understanding of tumor biology, adds additional layers to the underlying philosophy of osteopathic medicine going against the “one-size-fits-all” approach and allows for the potential of personalized cancer care. In the present article, we discuss the application of osteopathic principles and practice in the care of patients with cancer. Although great scientific progress has been achieved, as described in the following paragraphs, physicians are reminded of the 4 osteopathic principles: (1) the body is a unit, and the person is a unit of body, mind, and spirit; (2) the body is capable of self-healing; (3) structure and function are reciprocally related; and (4) a rational approach to treatment is based on an understanding of these principles.2 
Person Is a Unit
The first osteopathic tenet describes the human body as a unit and considers a patient's mind, body, and spirit throughout care. The idea that the body is a unit is vital for providing care to patients with cancer. Physicians must acknowledge that cancer can have effects beyond physical manifestation, including emotional and spiritual ramifications. Furthermore, it is common to describe people with cancer as “warriors” who “battle” cancer, but using this language can make people feel as though they are quitting or giving up if they decide not to take futile toxic chemotherapy in the setting of advanced incurable disease.3 Part of our job as physicians is to remember that a disease cannot be “fought” at the expense of the patient. 
Body Is Self-Healing
Through the tradition of Still, osteopathic manipulative medicine is used to promote self-healing. For example, osteopathic manipulative treatment techniques that target the immune system have shown that the body has the inherent capacity for self-healing.1 The principle of self-healing is still applied when considering the biological basis of cancer and the role of the individual patient's immune system. In cancer research and therapy, the pendulum is moving away from cytotoxic chemotherapeutics and toward harnessing the power of the immune system. For example, immune-based therapy has shown promise in numerous malignant tumors, including melanoma, non–small cell lung cancer, renal cell carcinoma, hepatocellular carcinoma, and solid tumors with high microsatellite instability (MSI-high).4-6 
Although there has been success in treating patients with immunotherapy, most patients do not respond to this treatment.7,8 However, researchers are starting to unravel the mechanisms behind this resistance to immunotherapy. For example, patients with metastatic melanoma who were nonresponders to ipilimumab, an anticytotoxic T-lymphocyte antigen protein 4 antibody, were found to have tumors with genomic defects in the interferon γ pathway.3 Thus, an alteration in the structural framework of the interferon γ pathway led to a loss of drug function. In cancer research, structural changes in key biological pathways have been shown to have a beneficial effect on cellular function and adversely affect therapeutic intervention.14,15 
Interrelation of Structure and Function
The osteopathic tenet that structure and function are reciprocally related is best illustrated in the evolving knowledge of cancer biology and our understanding that cell and molecular biology governs function. The advanced genomic editing system CRISPR/Cas9 has revolutionized the way scientists can manipulate DNA. The bacterially derived CRISPR/Cas9 system is composed of a nuclease protein, Cas9, which cuts double-stranded DNA along with a guide RNA molecule that directs Cas9 to a specific DNA sequence.9-13 The CRISPR/Cas9 system highlights how specific genetic mutations alter a malignant phenotype and allows for expeditious preclinical modeling of specific targeted therapies, thus helping researchers continue to discover how underlying molecular structural alterations can influence outcomes. 
The structure and function relationship is further demonstrated in a tumor's mutational status. In colorectal cancer, mutational analysis, including tests for KRAS, NRAS, and BRAF mutations and MSI-high tumors, has enabled personalized therapy beyond standard TNM staging–based therapy.14 Researchers are able to tailor treatments to maximize efficacy as the understanding of both somatic and germline mutations improves. For example, patients with resected colorectal liver metastasis harboring a KRAS mutation were found to have a significantly worse 3-year recurrence-free survival after adjuvant hepatic artery infusion plus systemic therapy than patients with KRAS wild-type mutations.15 Additionally, the epidermal growth factor receptor, or EGFR, antagonist cetuximab has been shown to provide no survival advantage in patients with a KRAS mutation.16 On the other hand, patients with solid organ MSI-high tumors have shown a greater response to immune checkpoint inhibitors, specifically nivolumab.17 Therefore, by understanding the differences in tumor mutational status, therapies can be directed toward the individual patient rather than the disease. This approach can save patients from unnecessary procedures and therapies, which all carry risk. Furthermore, as researchers and physicians better understand a patient's genetic structure, treatment can be tailored to fit a genetic phenotype. For example, a germline BRCA mutation is known to confer a high risk of breast as well as ovarian cancer in woman. As the genetic structure of BRCA is altered, there is a loss of function of tumor suppression, leading to an increased risk of cancer. As a result, prophylactic surgery is routinely recommended to decrease the risk of cancer.18,19 
Rational Approach to Treatment
As scientists make advances in the basic understanding of cancer biology, this knowledge must be translated to the bedside. Cady20 highlighted the importance of understanding tumor biology and its role in the development of a rational treatment strategy, whereby patients with cancer undergo an operation for their disease, but without proper selection, aggressive biological processes will override even the most technically sound procedure or advanced targeted or immune-based therapy.20 
The principle of rational therapy is exemplified in pancreatic adenocarcinoma, where patient outcomes have not improved despite increased understanding of the complexities of both genetics and epigenetics and the interplay of the tumor cells, the stroma, and the immune system.21,22 Pancreaticoduodenectomy is the lone option to achieve long-term survival, but it is not without associated high postoperative morbidity. Additionally, even with the most technically sound procedures, most patients will have recurrence, often in the form of liver metastasis.23 Preclinical data have shown that pancreatic cancer metastasis often occurs early in the course of disease, making resection a fruitless endeavor.24 Therefore, one may argue that patients with potentially resectable pancreatic cancer should receive upfront neoadjuvant chemotherapy to address micrometastatic disease. Patients who receive neoadjuvant chemotherapy are more likely to complete the treatment regimen, and neoadjuvant therapy allows for a window of time to test for unfavorable tumor biology.25,26 Patients at risk for metastatic disease could therefore avoid the morbidity of an operation that would be of no therapeutic benefit. 
Conclusion
The climate of cancer research encompasses much of the osteopathic philosophy. Scientific advances leading to a more in-depth understanding of tumor biology have led to novel treatments to battle cancer, allowed for a more personalized approach to cancer care, and rebelled against the “one-size-fits-all” model. In managing a disease that truly affects the person as a whole, physicians must remember Still's maxim: “To find health should be the object of the doctor. Anyone can find disease.”27 
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