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Timothy Birdsall, ND: facilitating hope in integrative cancer treatment. Interview by Frank Lampe and Suzanne Snyder.

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ALTERNATIVE THERAPIES
IN HEALTH AND MEDICINE
A peer-reviewed journal • jul/aug 2009 • VOL. 15, NO. 4 • $6.95
RESEARCH LITERACY IN A CAM CURRICULUMREIKI IN THE ELDERLY WITH
DEMENTIAPROBIOTICS FOR NECROTIZING ENTEROCOLITISTHE ECOLOGY
OF EATINGSTINGING NETTLE CREAM FOR OSTEOARTHRITISYOGA FOR
RHEUMATOID ARTHRITISCONVERSATIONS/TIMOTHY BIRDSALL, ND
64 ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 Conversations: Timothy Birdsall, ND
Donovan, naturopathic physicians in the Seattle area, were the
rst NDs to be hired by CTCA at our clinic in Seattle. I was familiar
with CTCA—only peripherally—based on their involvement. I
had the opportunity to meet a couple of folks from CTCA at a con-
ference that I was attending, and that turned into an invitation to
come to the Midwestern Regional Medical Center just outside of
Chicago to present a grand rounds.
I did that in the spring of 1998, and at that time, based on the
experience in the Seattle clinic, the CTCA leadership had made the
determination that they wanted to add naturopathic positions at all
of their facilities. The hospital in Illinois was in the process of fi gur-
ing out how to add naturopathic medicine there, which would have
been the fi rst inpatient facility at CTCA to have naturopathic physi-
cians. I just happened to be in the right place at the right time.
I was so impressed by what I saw, by the level of care that
was being provided to patients, by the openness to alternatives
to conventional therapy. One thing led to another very quickly.
I found CTCA very interesting and exciting, and they were look-
ing for a naturopathic physician to provide some leadership for
that program. By summer, I had relocated to Illinois and was
working at CTCA.
I started as the director of naturopathic medicine at the hos-
pital in Illinois and also as the national director of naturopathic
medicine for the entire corporation and stayed in that role until
about 2003. At that point, I was promoted to vice president of
integrative medicine, which is the role that I’m currently in. In this
role, I have responsibility for all of the integrative medicine modal-
ities programmatically at CTCA. That includes nutrition, natur-
opathic medicine, mind-body medicine, pastoral care, oncology
rehabilitation, acupuncture, and chiropractic. I have responsibility
for those programs around the enterprise.
ATHM: In addition to your corporate role, you are a practitioner
on staff at the Phoenix facility. How does that benefi t you and the
organization?
Dr Birdsall: I’m a clinician at heart. Seeing patients is a vital part
of making me effective as a leader. Frankly, it’s a vital part of me
As vice president of integrative medicine at Cancer Treatment
Centers of America (CTCA), Timothy Birdsall, ND, oversees a unique
treatment model that combines state-of-the-art conventional medical
treatments with scientifically supported complementary therapies.
CTCA cancer experts deliver this care in a patient-centered environment
designed to meet the special, whole-person needs of cancer patients.
A well-known lecturer and naturopathic physician, Dr Birdsall is
a sought-after presenter at medical conferences worldwide. He earned a
doctorate of naturopathic medicine from Bastyr University in Seattle,
Washington, where he served on the faculty for 5 years. He is also a fel-
low of the American Board of Naturopathic Oncology.
In January 2008, US Health and Human Services Secretary Michael
Leavitt appointed Dr Birdsall to serve a 4-year term on the National
Advisory Council for Complementary and Alternative Medicine for the
National Institutes of Health. Dr Birdsall’s professional achievements
also include serving as speaker of the house of delegates and vice president
of the American Association of Naturopathic Physicians. In addition, he
currently services on the board of directors of the Oncology Academy of
Naturopathic Physicians and is chair of the American Board of
Naturopathic Oncology.
Dr Birdsall was the founding editor in chief of Alternative
Medicine Review, the fi rst peer-reviewed medical journal edited by
naturopathic doctors to be indexed on MEDLINE. He coauthored the
book How To Prevent and Treat Cancer With Natural Medicine.
Currently, Dr Birdsall serves on the editorial consultants board for the
journal Integrative Cancer Therapies.
For his extensive experience in the area of naturopathic medicine,
Dr Birdsall has been recognized in American Men and Women of
Science, Who’s Who in America, Who’s Who in Science and
Engineering, and Who’s Who Registry of Global Business Leaders.
Alternative Therapies in Health and Medicine (ATHM): How long have
you been affi liated with the Cancer Treatment Centers of America?
Dr Birdsall: I’m going on 11 years with CTCA. I started at
Midwestern Regional Medical Center, Zion, Illinois, the CTCA
agship hospital, in 1998.
ATHM: What led you to CTCA, and how did you move into the
role that you currently have?
Dr Birdsall: Two colleagues of mine, Dr Paul Reilly and Dr Patrick
TIMOTHY BIRDSALL, ND: FACILITATING HOPE
IN INTEGRATIVE CANCER TREATMENT
Interview by Frank Lampe and Suzanne Snyder • Photography by Carrie Rosinski
Opposite: Timothy Birdsall, ND, shown here at CTCA, believes that
taking an integrative approach to cancer treatment is the best way to
not only optimize outcomes but to improve patients’ quality of life.
CONVERSATIONS
ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 65
Conversations: Timothy Birdsall, ND
66 ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 TKConversations: Timothy Birdsall, ND
staying sane. As a matter of fact, if I get a little cranky, my wife is
likely to suggest that I need to see a few more patients because I
love working with patients. Far too often in medicine, healthcare
decisions, particularly in large organizations, are made by non-
clinicians or by people who are no longer active clinicians.
I value being able to sit in a room with a patient, listen to
her story, make suggestions and recommendations, and manage
complex medical problems and then walk out of the room, go
into a meeting, and talk about how we can improve our system of
care or delivery of care from a very different perspective than if I
was just an administrator looking at a sheet of facts and fi gures.
ATHM: When CTCA decided to
bring on NDs, was it focused spe-
cifi cally on NDs, or was it bringing
on other practitioners with an inte-
grative medicine focus as well?
Dr Birdsall: For a long time, CTCA
has had an approach of utilizing all
of the appropriate resources to deal
with cancer and to assist cancer
patients. We spend a lot of time talk-
ing to our patients and determining
what they value. There are many
integrative approaches at the CTCA
that have been around for a long,
long time and that certainly predate
naturopathic medicine. That would
include intensive nutritional inter-
vention, as well as a variety of mind-
body therapies including everything
from psychotherapy to Reiki therapy
and biofeedback—a whole variety of
approaches like that. So naturopath-
ic medicine is certainly not alone.
Integrative medicine at CTCA is not an add-on. At many
other places, particularly large academic medical centers, espe-
cially with inpatient-based medical care, my experience has been
that integrative medicine is an add-on. It’s an afterthought.
CTCA is completely committed to an integrative approach.
Integrative medicine actually formed the foundation of CTCA in
terms of what we believed that we wanted to provide.
CTCA is now 20 years old, and some of the predecessor
organizations go back another decade or so before that. It is such
a deep part of what we do. It’s imbedded into our mission state-
ment and into what we call our promise to our patients. Our mis-
sion statement says, “CTCA is the home of integrative and
compassionate cancer care. We never stop searching for and pro-
viding powerful and innovative therapies to heal the whole per-
son, improve quality of life, and restore hope.” So “integration”
is right there in the fi rst sentence of the mission statement.
It is who we are, and I find that to be truly unique. Our
promise to our patients says, “You and your healing are at the
center of our hearts, minds, and actions every day. We rally our
team around you, delivering compassionate, integrative cancer
care for your body, mind, and spirit. We offer clear information,
powerful and thorough treatment options, all based on your
needs. We honor your courage, respect your decisions, and offer
to share your journey of healing and hope.” Integrative care is
right there at the front and center of what we promise we’re
going to deliver to our patients.
ATHM: During all of the years that you have been at CTCA and work-
ing as a clinician, what kind of changes have you observed in oncology
with regard to patient care?
Dr Birdsall: There are some very
dramatic and exciting changes in
oncology. A couple of major shifts
have occurred in the last decade.
First of all, oncology care itself was
limited from a conventional stand-
point to the 3 traditional pillars of
cancer care: surgery, radiation ther-
apy, and chemotherapy. On the
conventional side, there have been
some dramatic breakthroughs.
They haven’t translated yet to any-
thing that would approach a cure,
in general, but nonetheless, there
have been significant break-
throughs in the areas of what we’re
calling targeted therapies, such as
monoclonal antibodies that are
specifi cally targeted to cancer cells,
drugs like Rituxan and Herceptin,
and some of the other therapies
that are targeted to specifi c recep-
tors on cancer cells, such as epider-
mal growth factor receptors and vascular endothelial growth
factor receptor.
We are becoming much more specifi c. We’re starting to use
data from the Human Genome Project to help predict who will
respond to conventional treatment. There is a new test available
called Oncotype DX, which looks at a panel of genes in a patient’s
cancer and determines from their analysis whether that patient
will benefi t from receiving chemotherapy. We can now individu-
alize our therapies, whereas in the past, conventional approaches
to oncology just categorized people into big groups and said,
“You’ve got stage II breast cancer, so you need to get X.” Or,
“You’ve got stage III colon cancer, so you need to get Y.”
Now we can individualize therapies much more precisely. I
would predict that in another 10 years, most cancer therapy will
be driven by molecular and genetic analysis of the tumor, not by
the organ system where it starts. Currently, we categorize cancer
as breast cancer, lung cancer, colon cancer, or prostate cancer,
and we treat cancers in each of those categories more or less the
THE CARE
THAT MOST
PATIENTS
GET IS VERY MUCH
FOCUSED ON A
TUMOR. THERE IS
VERY LITTLE FOCUS
ON THE INDIVID-
UAL WHO HAS
THE TUMOR.
ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 67
Conversations: Timothy Birdsall, ND
same. We’ve gotten a little bit more sophisticated in the last few
years, but we are now at the point where we know that there are
common genetic mutations that cross those organ system lines.
What we’re seeing now is testing that says, “Your cancer is
either positive or negative for this genetic abnormality. That
means you are either a candidate for or not a candidate for drug
X.” It doesn’t matter whether you’re talking about a patient with
breast cancer or ovarian cancer or colon cancer. If your cancer
exhibits this abnormality, we’re going to give you the drug. If you
don’t have this abnormality, we won’t.
Oncology is going to become a very individualized approach
to medicine. That fits right in
with an integrative model on a
philosophic level anyway. I’m
very excited about that change.
On the integrative side of
things, we have seen a lot of
major cancer centers starting to
pay attention to patients’ needs
in the areas of integrative medi-
cine. We’re seeing major cancer
centers like Memorial Sloan-
Kettering Cancer Center in New
York City and MD Anderson
Cancer Center in Houston with
integrative medicine clinics as
part of their centers. They are
offering therapies like nutrition-
al counseling and acupuncture.
That’s also very exciting to
me. As a matter of fact, there
was a new organization formed
about 5 years ago called the
Society for Integrative Oncology
with the sponsorship and sup-
port of major cancer organiza-
tions in the United States like
the American Society for Clinical
Oncology and the American
Society for Therapeutic
Radiation and Oncology. It is great that major organizations
sponsored the founding of a new professional society that is total-
ly focused on integrative oncology.
ATHM: Is CTCA the only group of care centers that has an inte-
grative approach to oncology? Or are we starting to see more of
this in other facilities?
Dr Birdsall: I feel confident in saying that CTCA is the only
nationwide, hospital-based oncology provider that programmati-
cally includes integrative medicine as its underlying philosophy
and where integrative options are offered to every single patient.
Right now, to the best of my knowledge, every other cancer facili-
ty that’s offering any type of integrative services makes them
available only when ordered by the attending physician or only if
patients request the services. But patients are not automatically
offered integrative options at most other centers.
At CTCA, every single patient walking in the door is going to
speak to a nutritionist, meet with a naturopathic physician, be told
about acupuncture, have conversations about mind-body tech-
niques. We’re not here to force any integrative therapies down any-
one’s throat. A patient can say, “I don’t want acupuncture” or “I’m
not interested in herbs.” That’s fi ne. But we feel it is our obligation
to educate patients and to present that information. I believe that
CTCA is the only hospital-based provider in the country that is
programmatically offering those kinds
of options to every cancer patient who
walks in the door.
ATHM: CTCA founder Richard
Stephenson has been quoted saying,
“What were regarded as world-
renowned cancer treatment facilities
were singularly focused on the clinical
and technical aspects of cancer treat-
ment, ignoring the individual needs
of the patient and the multifaceted
nature of the disease.” Do you feel
this is still the case?
Dr Birdsall: In my experience dealing
with thousands of cancer patients
over the last decade, unfortunately,
the answer is still yes. The care that
most patients get is very much
focused on a tumor. There is very lit-
tle focus on the individual who has
the tumor. There are exceptions to
that, but they are few and far between,
and the vast majority of the patients I
talk to come to CTCA because they
are looking for something that hasn’t
been offered to them in their local
facilities. So while there has been
much change and there is a lot more discussion about addressing
the larger needs of cancer patients, oftentimes we fall short in the
delivery of services targeted toward that.
ATHM: Has the CTCA model infl uenced patient care at other
centers?
Dr Birdsall: I honestly believe that CTCA is a change agent. That’s
part of what attracted me to CTCA—I felt like I could participate
in the process of changing healthcare. My secret agenda is to revo-
lutionize healthcare in America. I see cancer treatment as a place
from which I can do that.
CTCA has been very public about what we do. We advertise
directly to patients, to consumers. We are not structured in the
My secret
agenda
is to
revolutionize
healthcare in
America. I see
cancer treat-
ment as a place
from which I
can do that.
68 ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 Conversations: Timothy Birdsall, ND
typical referral patterns that govern most specialty care in
America. We don’t have a group of local primary care doctors
who refer their patients to us and therefore to whom we are
beholden. We are beholden to one person: the patient.
Because we advertise our services directly to consumers,
consumers get educated. Even people who don’t choose to come
to CTCA are a little bit more educated about some of the ques-
tions they should be asking and push their local providers to add
more of the services that that cancer patients need.
ATHM: In CTCA’s model of care, you offer something that you call
“comfort rounds.” What is it, and how does it affect patient care?
Dr Birdsall: Comfort rounds is an interdisciplinary approach to
dealing with issues that cause patients discomfort. It grew out of a
more traditional pain rounds type of an approach. But we quickly
realized that if all we did was deal with patients’ physical pain,
they oftentimes were still uncomfortable but for other reasons.
So we have a multidisciplinary team that includes pain man-
agement physicians and nurses or physician assistants, natur-
opathic physicians, acupuncturists, mind-body therapists,
pastoral care staff who round on our inpatients and ask the sim-
ple questions, “Are you comfortable? What can we do to make
you more comfortable?”
The answer may be, “I’m in a lot of pain.” We can address
that in a variety of ways. We may change their dose of narcotics.
We may have the massage therapists come in to provide some
musculoskeletal relaxation. We may have the acupuncturist do
acupuncture. Or we may do a combination of all of those things.
The patient may say, “I’m really uncomfortable; I could use
another pillow.” Our job is to get the pillow. Or it may be, “I’m
really uncomfortable because I love my dog and I have been here
for 10 days without my dog, and I miss her.” In that case we
might arrange for one of our therapy dogs to visit the patient or
perhaps have a friend or family member at home e-mail us some
snapshots of the dog.
Sometimes people are concerned about end-of-life issues.
Cancer is an interesting disease because unfortunately, even in
2009, about 50% of people diagnosed with invasive cancer this
year will die from that diagnosis. But the vast majority of them
will not die quickly and will live for years, knowing that most
likely the disease will ultimately take their life.
Cancer forces us to confront our own mortality and to
maybe ask questions about the nature of life and death that we
would not have thought to ask previously. At CTCA, we take the
opportunity to provide patients with a forum to discuss those
issues with someone from our pastoral care staff or our mind-
body medicine.
“I am going to do for a patient exactly what I would do if that patient were my
mother. If you think about it in those terms, it has a profound impact on how
we treat people.”
“For a long time in medicine, there has been a perception that we need to
distance ourselves from our patients, that we should not get emotionally
involved.”
ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 69
Conversations: Timothy Birdsall, ND
Comfort rounds is really designed to look at the entire
gamut of discomfort—all the way from straightforward, physical
pain to psychological, emotional, and even spiritual discomfort
and to make sure that we’re creating an environment where
those things can be addressed.
ATHM: You use what you refer to as the “Mother Standard.”
What is it, and why does CTCA believe it is important?
Dr Birdsall: The Mother Standard is a very simple concept: it is
treating every single patient the way you would want your moth-
er, your father, your brother, or your sister to be treated. At
CTCA, it comes directly from the circumstances that surrounded
our founding. Our chairman, Richard J Stephenson, tragically
lost his mother to cancer. She was not offered the type of care,
options, or support that would have been most helpful for her.
At its core, CTCA really is about a son taking care of his moth-
er. And as a clinician, that’s how I see every one of our patients. I am
going to do for that patient exactly what I would do if that patient
were my mother. If you think about it in those terms, it has a pro-
found impact on how we treat people. They’re no longer patients;
they’re family. They’re no longer a diagnosis; they’re people. They’re
no longer your 2:30 appointment that you have to rush through
because you have another one at 2:45. It’s taking care of that person
the way you would take care of a loved family member.
ATHM: Treating patients in that manner must lead you to get
emotionally involved with them. That must be diffi cult.
Dr Birdsall: For a long time in medicine, there has been a percep-
tion that we need to distance ourselves from our patients, that we
should not get emotionally involved. There are some risks with
getting emotionally involved with your patients. The risk is that
you may lose some of your objectivity. You also risk losing some-
one to whom you have become close. But the benefits to both
patient and provider far outweigh the risks. For me, it is a unique
privilege to embrace my patients, both physically and metaphori-
cally, and to walk their journey hand in hand with them.
We take extraordinary means to be very careful in making
hiring decisions at CTCA. Patients and others who visit and tour
our facilities—particularly if they’ve interacted with any of our
stakeholders, which is what we call our employees—ask ques-
tions like, “Where do you find these people?,” “Do you have
some sort of a special training program you put them through?,”
“Do you feed them happy pills?”
We don’t give them happy pills, but we do diligently search
out people who are compassionate and who will engage and inter-
act with and develop relationships with patients. That’s not just
the clinicians. It’s not just the nurses. We use those same standards
for hiring people in our housekeeping department, our food ser-
vice department, and our maintenance department because those
people are going to interact with patients all the time.
It is not unusual to see a housekeeper in an inpatient room
cleaning the room and having a conversation with the patient.
We facilitate and encourage that.
There is one statement that is always considered to be the high-
est priority. If I walk into a meeting late, even a meeting with the
chairman of the board, because I’ve been with a patient, all I need to
say is, “I’m sorry I’m late. I was with a patient,” and that answers all
questions. If there is a question about whether or not we should do
something, the question that stops the debate and just moves the
conversation along down the road is, “Is this best for the patient?”
When you hire the right people and put them in an environ-
ment that not just allows but encourages them to develop that
kind of relationship with a patient, you create a place that becomes
a home away from home for patients. Do we get too close to our
patients sometimes emotionally? It can be a challenge. Working
with this patient population, we have patients who die.
If you’ve worked at CTCA for very long at all, you’ve got 1 or 2
or 3 or a long list of patients whom you really cared about, whom
you really connected to who have passed away. That’s the nature of
life; that’s the nature of humanity. I consider it a huge privilege to
be able to interact with patients in that way at a point in time when
they have such signifi cant, sometimes even desperate, needs. It’s
not always easy, but for me, it’s very rewarding.
ATHM: Can you put a value on how important “whole-person
cancer treatment in a compassionate, nurturing environment,”
is in terms of effecting positive outcomes?
“If there is a question about whether or not we should do something, the
question that stops the debate and just moves the conversation along down
the road is, ‘Is this best for the patient?’”
70 ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 Conversations: Timothy Birdsall, ND
Dr Birdsall: From a purely analytical standpoint, doing a con-
trolled trial of compassionate, nurturing care from a whole-
person perspective is a diffi cult thing because you would have to
come up with whatever the opposite of that is and provide it to
half the people. What we can demonstrate is that our patients
achieve some very dramatic outcomes, particularly in the areas
of optimism and quality of life.
We have published several dozen articles and abstracts in
the medical literature on our outcomes using this model in look-
ing at objective quality-of-life measures. We published an
abstract on naturopathic interventions for pancreatic cancer and
their ability to improve both pain and fatigue scores in patients.
We see some very dramatic results
in that regard.
On a philosophical level, I
don’t see any other way to provide
care, particularly for a disease like
cancer. You have to look at the entire
person; you have to look at the entire
family system and the entire dynam-
ic going on with that person to be
able to treat it effectively.
Obviously, cancer is not some-
thing that we can say we have
reached the zenith of our ability to
treat. If 50% of the people who con-
tract cancer are going to die from
it, we’ve got a long, long way to go.
We are fi guring out the tech-
nical, scientifi c, and biologic pieces
of that, but as we go, it seems
incomprehensible to me that we
wouldn’t do that in a compassion-
ate, nurturing environment. If you
can’t guarantee that you can cure
someone, at the very least, you can
be compassionate and understand-
ing and supportive.
ATHM: With 50% of patients diag-
nosed with cancer likely to die
from the disease, how does CTCA
measure success in terms of the patient outcomes?
Dr Birdsall: There are a variety of ways to measure success.
Outcomes is certainly one of them. You have to be careful about
which outcomes you look at and how you track and defi ne them.
We have looked at a variety of outcomes in different cancer types.
For example, we’ve talked about some of the quality-of-life
issues that we have been able to identify and drill down on.
Pancreatic cancer is the one that comes to mind. Pancreatic can-
cer is probably the most lethal common cancer. We have pub-
lished quite a bit of data looking at pancreatic cancer and
outcomes, and we’ve compared our outcomes to other publicly
reported data in the SEER—Surveillance, Epidemiology and End
Results—database at the National Cancer Institute and looking at
survival. In the study, we demonstrated that pancreatic cancer
patients treated at CTCA live significantly longer than similar
stage pancreatic cancer patients reported in that national data-
base. We are tracking a variety of things like that.
There are a lot of other kinds of intermediate endpoints
other than just survival. As I mentioned, quality of life is certain-
ly a huge one. If all we did was improve pain and fatigue in cancer
patients—and we’ve been able to demonstrate in several differ-
ent groups that we can do that—that would be major news.
Outcomes are an appropriate way to measure how facilities
perform. For us, probably the most
important measure is what our
patients tell us. We have what we
call patient loyalty surveys that we
use with all of our patients to survey
their reactions to their visit with us.
We learn a lot about what we could
do better. We also learn a lot about
how our patients perceive us and
whether they would recommend us
to a friend or family member.
We’ve used data-gathering
tools that have been used by many
other companies, including the net
promoter score, which is a concept
that originated with Bain and
Company on the East Coast with
Fred Reichheld. Our net promoter
scores, which represent patients
who are incredibly loyal, vocal sup-
porters of CTCA, are higher than
the net promoter scores for world-
class companies such as Ritz-
Carlton or some of the luxury
automakers. They tell us how well
we’re doing, but they also tell us
where to improve. We listen to our
patients, and ultimately, that’s the
biggest measure of success.
ATHM: One criticism that has been leveled against CTCA is that
it offers false hope to very ill patients who have been offered no
further conventional treatment. How do you respond to that?
Dr Birdsall: CTCA’s approach has been to evaluate every patient
as an individual and to determine what other therapies might be
appropriate. From my perspective, there’s no such thing as false
hope for a cancer patient unless you’re lying to them. If you tell a
patient that something is going to work when there’s no reason to
suspect that it will, that would be offering false hope, and we
would never do that to a patient. However, many patients who
have been told elsewhere that there were no other options left for
M
any
patients
who
have been told
elsewhere that
there were no
other options
left for them
come to us, we
treat them, and
they have remark-
able results.
ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 71
Conversations: Timothy Birdsall, ND
them come to us, we treat them, and they have remarkable results.
In some cases, frankly, they are cured. I have 4 or 5 patients now,
long-term cancer survivors with no evidence of disease, who were
told elsewhere that there were no other treatment options for
them. We treated them, and they’re disease-free today.
Even if a patient ultimately succumbs to the disease, often-
times we provide them with a much longer life than they were
told to expect. A very dear friend of mine who passed away
recently had been diagnosed with metastatic breast cancer—
widely metastatic to multiple internal organs and multiple
bones—and was told that there were no treatment options avail-
able for her. She went to several major medical centers in the
United States. You would recognize all of their names if I told you
what they were. She was told by all of them, “There’s nothing else
that can be done.”
She came to CTCA, we treated her, and she lived 16 years.
Did she ultimately die from her breast cancer? Unfortunately, she
did. But, in her words, “CTCA gave me 16 more years.” Was that
false hope? I don’t think so. Had she been told by very reputable
oncologists at leading institutions that there was nothing that
could be done? Yes, she had. Were they wrong? In retrospect, yes,
they were. Do we have that kind of result with every patient?
Absolutely not, unfortunately. But we treat patients as individu-
als. Oftentimes when a patient’s told, “There’s nothing more that
can be done,” what is really being said is, “There are no standard
protocols for your situation. You have X cancer, you’ve been on 3
chemotherapy regimens, and your disease has progressed
through each one of those. There are no other regimens that are
routinely used if you have gone through 3 things that don’t work;
there is no regimen number 4 that’s generally agreed upon as a
national guideline, what we would call fourth-line chemotherapy.
There is none.”
That doesn’t mean that there aren’t chemotherapy regi-
mens that can be used. It doesn’t mean that there aren’t tech-
niques that can be employed. What most cancer patients don’t
realize is that what some facilities—particularly small commu-
nity hospital–based cancers centers or outpatient medical
oncology offi ces—can do is very limited based on the technolo-
gy that’s available.
For example, there are wonderful, interventional radiology
techniques available now that allow us to target chemotherapy
directly to the tumor. But in order to do that you need a high-
tech approach, including a very skilled interventional radiologist
and a medical oncologist who is comfortable with administering
chemotherapy in that way.
We can target specifi c, even metastatic, cancer lesions in the
liver, for example. They can be treated very effectively, but only if
you’ve got the technology available to do that. So I don’t think
that the false hope criticism is a valid one. Are there times when
patients come to us and we tell them, “There’s nothing that we
can do for you”? Yes, there are times like that. What we do pledge
to our patients is that we’ll evaluate them as individuals, and we
will be unceasing in our efforts to identify something that might
help. We will stand shoulder to shoulder with them as long as
they want to fi ght this disease, and we will work to fi nd ways to
treat it. We will respect their decisions. We will never push them
for treatment when they don’t want to be treated. If we have
options and it’s feasible for us to treat them, we are going to offer
those and let them make the decision.
ATHM: Are there any natural therapies that CTCA uses that have
been shown to be effective in oncology and cancer treatment?
Dr Birdsall: We do not do alternative cancer therapy in the stan-
dard sense of it. That is, all of our patients are receiving an appro-
priate standard of care: surgery, radiation therapy, chemotherapy.
There are times with some diseases when a patient is known to
have cancer but when treatment may not be appropriate.
Watchful waiting in prostate cancer, for example, is a well accept-
ed approach in certain age groups. At certain PSA levels, it’s
appropriate to simply observe the disease.
Do we observe? Yes. Do we stop at observation? No. We are
doing a whole variety of nutritional interventions and natur-
opathic interventions and other things to attempt to change the
course of the disease. But we don’t do alternative medicine to the
exclusion of conventional approaches. I would be hard-pressed
to give you a single example in nearly 11 years where it was
appropriate to treat a patient with conventional therapy and the
patient only received a naturopathic orientation.
Certainly, we have found some things to be very effective: a
whole variety of natural therapies, some of them aimed at reduc-
ing side effects of treatment or symptoms of the disease itself,
some at improving the patient’s ability to tolerate other treat-
ments, some at stabilizing metabolism or boosting immune
function. There are a whole variety of things.
We carry well over 150 natural products plus a couple hun-
dred homeopathic remedies in our hospital pharmacy to be dis-
pensed to inpatients and available for outpatients. We use those
frequently, as they are appropriate for the patient’s situation.
Some botanical products have very interesting research
behind them: green tea; black cumin; some of the medicinal
mushrooms: the Coriolus, reishi, shiitake, maitake—all have
some areas where we would use them. Even things like ginger for
nausea can be very effective.
We typically look at the kind of disease the patient has, the
kind of treatment he is going to be receiving, and what else is
going on with him medically, and then we weigh all of those fac-
tors as we determine what kind of natural product recommenda-
tions to make.
ATHM: In the model of care at CTCA, do the naturopathic physi-
cians and the oncologists offer joint visits to patients? And if so,
what have you learned from that?
Dr Birdsall: We function in a very integrative team environment.
We are currently involved in the early phases of a project that will
completely reframe and restructure the way that we provide care
for our patients. We do joint visits with patients occasionally, but
72 ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 Conversations: Timothy Birdsall, ND
that is not the norm. We have a comprehensive electronic medi-
cal record system at CTCA, and all of our practitioners chart in
that. We meet together as a large team 3 times a week and talk
about patients.
Going forward with this new team model that we’re imple-
menting—which, by the way, we have been using at our hospital in
Arizona for about 4 months—the team will actually sit down every
morning and talk prospectively about the patients that are coming
in that day.
That team is made up of a medical oncologist, a clinic nurse, 2
nurse care managers who provide
continuity of care when our patients
are at home, a naturopathic physi-
cian, a nutritionist, and a mind-
body therapist. They are all part of
that discussion. We literally talk
about every single patient coming
into the clinic that day.
It is a sort of rotation system.
In Arizona, for example, the medi-
cal oncologist goes in to the see the
patient. The naturopathic physician
follows him into the room. There is
a verbal hand-off between the medi-
cal oncologist and the naturopathic
physician. They may interact with
the patient simultaneously for a
brief period of time. We do try to
have joint visits in the initial treat-
ment planning session where treat-
ment options are being laid out for
patients, but that doesn’t necessari-
ly occur every time. It doesn’t need
to occur every time because the pro-
viders are talking multiple times
about every patient every day.
ATHM: One of CTCA’s calling cards
is its involvement in and support of research. Please discuss the cen-
ter’s research efforts.
Dr Birdsall: CTCA supports research in a couple of different ven-
ues. We underwrite all of the operating expenses of Gateway for
Cancer Research, which is a 501(c)(3), nonprofit philanthropic
organization that supports cancer research around the globe. Some
of those funds support cancer research at CTCA, but most of them
support cancer research at other institutions, including major insti-
tutions around the world. And we have funded research at most of
the major universities in the United States.
The research that we fund through Gateway is focused on
translational research—that is, taking good ideas from the labora-
tory and moving them to the bedside. That’s an area of research in
oncology that has not traditionally been well funded or supported
in other venues. If you’ve got a pharmaceutical drug, obviously, the
pharmaceutical company has a lot of interest in moving it to the
bedside and will support that. But there is not a lot of funding in
support of nonpharmaceutical approaches.
I’m very excited about a couple of Gateway-funded trials that
we have done at CTCA. One is a trial of high-dose melatonin in
non–small cell lung cancer. We have completed enrollment in that
trial and anticipate having data analysis on that later this year.
Another is an FDA-monitored phase I trial on the use of intra-
venous vitamin C. Vitamin C has been around for a long time, obvi-
ously, but has never undergone a well-designed, formalized phase I
trial. Once we have completed gath-
ering the data from the phase I
approach, we hope to enter a phase
II trial.
CTCA also does self-funded
research. We have research activi-
ties in all of our facilities that run
the gamut—conventional drug tri-
als to some very innovative things.
We currently have an innovative
ovarian cancer vaccine trial under-
way at our facility in Illinois. We are
looking forward to expanding that
to our other hospitals as well. It is
an individualized vaccine that is
made from the patient’s own tumor
cells. We do surgery on the patient
and remove the cancer, and know-
ing that ovarian cancer patients are
at a very high risk for recurrence, we
take the cancer cells and develop a
vaccine against that patient’s own
tumor. We are developing a drug
that will only ever be used by one
person. We are actually immuniz-
ing the patient against her tumor
with the intent to reduce the risk of
recurrence down the road.
ATHM: Regarding the intravenous vitamin C trial you mentioned,
what kind of dosage are you working with?
Dr Birdsall: It is a dose-escalation trial using a modifi ed Fibonacci
schema, which means we keep increasing the dose until we see
problems with the patient tolerating the dose. The maximum
dose that the trial has planned to go to is the equivalent of about
300 grams.
ATHM: How does CTCA evaluate cost effectiveness? How do the
outcomes compare to those of other cancer treatment systems?
Dr Birdsall: We get asked that frequently, as you can imagine, by
third-party payers and others. We have looked at this question from
many different perspectives, and there are some interesting data
IF YOU TELL A
PATIENT THAT
SOMETHING IS
GOING TO WORK
WHEN THERE’S NO
REASON TO SUSPECT
THAT IT WILL, THAT
WOULD BE OFFERING
FALSE HOPE, AND WE
WOULD NEVER DO
THAT TO A PATIENT.
ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 73
Conversations: Timothy Birdsall, ND
that support CTCA as a very effi cient provider of oncology care.
CTCA has hired what is probably the world’s premier health-
care actuarial fi rm, Milliman and Company, to run numbers for us
and tell us how we’re doing in terms of effi ciency. The data from the
Milliman study indicates that if you look at what’s called a risk-
adjusted patient sample—that is, take our patients and adjust for
how sick they are and that type of thing—and then do a similar
comparison for other publicly available information, including
Medicare data, you will fi nd that CTCA is a very effi cient healthcare
provider. We provide more service for a dollar than you will get
from other standard and academic center–based cancer centers.
We have a huge orientation toward being effi cient providers of
care, but we do it from a totally different perspective. We have
adopted the Lean Six Sigma methodologies for reducing waste in
our system. Most places that adopt Lean Six Sigma do so from the
perspective of trying to reduce cost. We do it from the perspective
of trying to increase service to the patient. If we can fi nd a place
where we can reduce wasted time by staff or reduce dollar expendi-
tures, then we pump those resources back into providing the things
that patients value.
We end up providing better care and more care, as opposed to
the typical model in healthcare, which is cutting costs, which means
cutting service. You end up with continually declining service provi-
sion in most places, whereas at CTCA, we have been able to increase
the amount of service provided while becoming more effi cient.
ATHM: In a challenging time for the hospital industry, how has
CTCA been faring? Is the organization seeing any growth?
Dr Birdsall: CTCA continues to grow at dramatic rates. CTCA has
grown at nearly a 20% compound growth rate in the 10 years that
I’ve been here—year over year, 20% growth.
ATHM: How would you describe the current state of oncology with-
in the practice of naturopathic medicine?
Dr Birdsall: Oncology is very complex. And, what I’ve observed in
helping to build the naturopathic program at CTCA is naturopathic
oncology is a specialty in and of itself.
As a matter of fact, the Oncology Association of Naturopathic
Physicians was formed to provide a venue to create a professional
specialty in naturopathic oncology for naturopathic physicians. The
average naturopathic physician is well equipped to provide general
support for cancer patients, but cancer treatment is very complex
and requires detailed knowledge of therapies and drugs and interac-
tions between drugs and natural products that the typical natur-
opathic physician just isn’t going to have.
ATHM: CTCA works with postgraduate medical education and also
the Oncology Association of Naturopathic Physicians. Can you tell
us a bit about that?
Dr Birdsall: CTCA offers a naturopathic oncology residency train-
ing program at 3 of our hospitals. We started that because we saw
the need for advanced training. It is a very unique opportunity for
naturopathic physicians to be trained in a hospital environment, to
learn that side of medicine fi rsthand, as well as to get a fi rm ground-
ing in oncology—specifi cally, naturopathic oncology.
I see the development of residency training in naturopathic
medicine as a logical, almost inescapable conclusion going forward.
There have been multiple discussions about requiring residency
training for licensing. It has been part of the discussion in many of
the states that are considering licensing naturopathic physicians.
It’s one of those unfortunate chicken-or-the-egg kind of dilemmas
where if you don’t require it, it won’t spontaneously develop, but
you can’t require it until it’s established.
I truly believe that the naturopathic profession is moving
toward a system that will provide postgraduate training for the
majority of its graduates. And I believe that ultimately it will
become required.
ATHM: After graduating from Bastyr, you taught there for 5
years. Based on your experiences since then, what would you
change about naturopathic education to best prepare clinicians
for their work?
Dr Birdsall: The changes that we’ve seen in medicine over the last
10 years have been to move conventional allopathic medicine to
much more of an evidence-based approach to practice. I think that
naturopathic physicians need to be better trained to read and
understand research studies and trials and to understand the impli-
cations of their therapies.
Until very recently, naturopathic physicians were trained on
the healthy end of the spectrum. If you think about health as a spec-
trum, from vibrant health on one end to near death on the other
end, naturopaths have tended to function more on the healthy end
of things, whereas medical doctors tend to be trained and to func-
tion more on the severe disease end of that spectrum. Naturopathic
physicians need more training in advanced disease and serious
medical conditions to enable them to provide more continuous care
for their patients at whatever point they are at in that spectrum.
ATHM: Working with cancer patients on a daily basis, how do
you—both personally and professionally—heal the healer?
Dr Birdsall: When I went to naturopathic medical school and after
I graduated, my focus was on natural childbirth. I ran a birth center
in the Seattle area for several years. After I came to CTCA and had
been here a while, I was speaking at a naturopathic conference. In
the question-and-answer session, someone who knew me stood up
and said, “Tim, I know that you were involved in natural childbirth
for a long time. What is it like for you kind of working at the other
end of life?” I gave an answer that was probably a little too pat. A
very good friend of mine in the audience stood up and said, “Tim, I
don’t think that it’s different at all. I think you’re just midwifi ng a
different kind of transition.”
That really struck me. When I started at CTCA, I never sat
down and outlined what my clinical goals were or what my goals
74 ALTERNATIVE THERAPIES, jul/aug 2009, VOL. 15, NO. 4 Conversations: Timothy Birdsall, ND
as a provider were for this patient population. I was excited to be
at CTCA, and I was happy to be seeing patients in this environ-
ment and working on building a program.
About a year into it, I realized that I was really depressed. I
took a step back, reassessed things, and came to realize that, num-
ber one, I was going in with a goal—though I had never verbalized
it—of curing these patients. And I was failing at that because I
wasn’t curing them. When I realized that and was able to verbalize
it, I realized how stupid it was. I don’t know how to cure cancer. I
don’t know anybody who does. I was setting myself up for failure.
But what I realized I can do, in any situation, with any patient,
is I can make things better today. Maybe it’s because I prescribe an
herb that’s going to relieve their nausea. Or I give them an amino
acid that’s going to reduce their peripheral neuropathy. Or maybe
it’s that I sit and I hold their hands and I chat with them. Or maybe
I put my arm around them and cry with them. But I can make
things better for them today. I have learned to live in the moment
and to be okay with mourning losses. Sometimes I’m mourning
losses with my patients, mourning their losses with them.
Sometimes I’m mourning my own losses, my loss of the friendship
and relationship with someone.
That’s part of human existence. There’s the old saying about
the only things that are certain are death and taxes. That’s true. We
will all die. There is nothing that any of us can do to prevent that.
We can change the course, we can change the circumstances to
some extent, but in fact, we will all die. I can make things better for
patients today. I can help ease their discomfort. I can help give them
a good death. We talked about hope earlier. Sometimes hope is
hope for a cure. Sometimes hope is hope for less pain. Sometimes
hope is hope for a better day. And sometimes it’s hope for a good
death. I can facilitate those for people.
ATHM: You were appointed to serve a 4-year term on the National
Advisory Council for Complementary and Alternative Medicine of
the National Institutes of Health (NIH) a little over a year ago. What
are your impressions of NIH’s initiatives around integrative medi-
cine at this juncture?
Dr Birdsall: I have been very impressed with the dedication of the
NCCAM staff and very impressed with Dr Josephine Briggs, the
new director of the center. She has taken an approach of listening
very carefully. She has a large constituency to listen to, and she has
been talking to and listening to all of them. I fi nd her to be very
responsive to input and criticism.
I think we’re going to see signifi cant changes in direction and
orientation out of NCCAM over the next couple of years.
Unfortunately, the process moves slowly, and if you want to change
direction, you have to fi gure out what that direction is and then you
have to create initiatives and program announcements to tell people
what you’re looking for. Then you have to give them enough time to
create and submit the proposals. The proposals then go to scientifi c
review. And then, eventually, we on the advisory council get to look
at them. So it takes a while for change to happen.
But we are seeing a shift to much more meaningful CAM
research as opposed to the pharmaceutical methodology that has
been funded up until now. In many cases we have been funding the
equivalent of drug trials using natural products. Oftentimes, those
natural products are being applied in the research setting in ways
that they would not be used in clinical practice. I think the focus
right now is on designing more meaningful trials looking at whole-
systems research approaches and asking very specifi c, meaningful
questions that will help us fi nd answers to signifi cant questions
down the road. Part of NCCAM’s charter is to help inform the
American public about the things that they may be choosing to do.
The challenge is not to do investigative discovery kinds of
research about new natural product uses or applications but rather
to evaluate and assess the way natural products are currently being
used and asking whether it makes sense. For example, is chiroprac-
tic effective for low back pain? We ought to be able to answer that
question. Is acupuncture effective for migraine headaches or for
nausea? We should be able to answer that question so that people
will know how best to approach their healthcare. I think NCCAM
has got its eye on that ball, and I think it will be effective long-term
in providing those kinds of answers.
ATHM: If you were in charge of the national effort to fi ght cancer,
what would be your top priorities?
Dr Birdsall: It depends on how you define fighting cancer. To
reduce deaths due to cancer in the United States, there are some
very clear things that need to happen. I don’t believe I know how to
make them occur, but it is very clear that diet and lifestyle choices,
including exercise choices, are hugely important both in terms of
the risk of developing cancer and in effectively treating it.
Improving the diet of this nation, getting rid of the junk food
that is advertised as “cholesterol-free, no trans fatty acids” but con-
tains 12 pounds of sugar, as an example, are things that we simply
have to deal with. Tobacco use—my gosh—the numbers vary, but
the best statistics I can fi nd say that about 30% of all cancer in the
United States can be traced to tobacco exposure.
You look at the billions of dollars we spend fi ghting this dis-
ease that could be dealt with by addressing the tobacco issue.
Obesity is now identifi ed as a major risk factor for cancer. We have
suspected it for a long time, but I think we have overwhelming
proof at this point, and yet, as a country, we grow more and more
obese every year.
If we could address diet, lifestyle, exercise, and tobacco use, we
would dramatically reduce the incidence of cancer. If we can pre-
vent it from starting, then we don’t have to worry about how we
treat it.
Cancer is a diffi cult, complex disease. Based on my experience,
I believe that taking an integrative approach to cancer treatment is
the best way to not only optimize outcomes but also to improve
quality of life and provide individualized care that truly meets the
needs of each patient.
Article
Full-text available
This systematic review set out to summarize the research literature describing integrative oncology programs. Searches were conducted of 9 electronic databases, relevant journals (hand searched), and conference abstracts, and experts were contacted. Two investigators independently screened titles and abstracts for reports describing examples of programs that combine complementary and conventional cancer care. English-, French-, and German-language articles were included, with no date restriction. From the articles located, descriptive data were extracted according to 6 concepts: description of article, description of clinic, components of care, administrative structure, process of care, and measurable outcomes used. Of the 29 programs included, most were situated in the United States (n = 12, 41%) and England (n = 10, 34%). More than half (n = 16, 55%) operate within a hospital, and 7 (24%) are community-based. Clients come through patient self-referral (n = 15, 52%) and by referral from conventional health care providers (n = 9, 31%) and from cancer agencies (n = 7, 24%). In 12 programs (41%), conventional care is provided onsite; 7 programs (24%) collaborate with conventional centres to provide integrative care. Programs are supported financially through donations (n = 10, 34%), cancer agencies or hospitals (n = 7, 24%), private foundations (n = 6, 21%), and public funds (n = 3, 10%). Nearly two thirds of the programs maintain a research (n = 18, 62%) or evaluation (n = 15, 52%) program. The research literature documents a growing number of integrative oncology programs. These programs share a common vision to provide whole-person, patient-centred care, but each program is unique in terms of its structure and operational model.
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