Supporting immunotherapy treatment with integrative oncology approaches

Written By Nina Fuller-Shavel

Our Director, Dr Nina Fuller-Shavel, has recently co-authored a review paper with Dr Jonathan Krell, consultant medical oncologist at Imperial College London and HCA, on ‘Integrative Oncology Approaches to Supporting Immune Checkpoint Inhibitor Treatment of Solid Tumours’. In this blog Dr Nina summarises the paper, including some key actions people treated with immune checkpoint inhibitors can take to support their treatment and wellbeing.

Research paper overview

The goal of this review was to examine the role and practical applications of integrative oncology strategies in supporting immune checkpoint inhibitor (ICI) treatment of adult solid tumours. Several patient-associated factors affect ICI response, including genetics, systemic inflammation, the gut microbiota, and diet.

Current promising supportive interventions include:

  • a Mediterranean-style diet with over 20g of fibre

  •  regular exercise (particularly getting at least 150 minutes of aerobic exercise per week)

  • use of specific live biotherapeutics

  • minimisation of proton pump inhibitor (e.g. omeprazole) and antibiotic use (where possible), and

  • ensuring vitamin D sufficiency (blood test levels for 25-hydroxy-vitamin D of over 75 nmol/l without reaching toxicity levels),

with many other integrative oncology approaches under study.

Caution around medical cannabis use in patients on ICIs was advised in the review because some studies show reduced overall survival with more research needed, while mistletoe (Viscum album extract, VAE) therapy studies have not highlighted any safety concerns so far. Given the emerging understanding of chronic stress impact on ICI treatment outcomes, mind-body approaches require further investigation.

Please read the full text of the paper HERE if you are interested. Please note that this is a scientific journal article, so it is not written in plain language.

What are immune checkpoint inhibitors (ICIs)?

Immune checkpoints are a normal part of the immune system. Their role is to prevent an immune response from being so strong that it destroys normal, healthy cells in the body.

Immune checkpoints engage when proteins on the surface of immune cells called T cells recognise and bind to partner proteins on other cells, such as some tumour cells. These proteins are called immune checkpoint proteins. When the checkpoint and their partner proteins bind to each other, they send an “off” signal to the T cells, which can prevent the immune system from destroying the cancer.

Immunotherapy drugs called immune checkpoint inhibitors (ICIs) work by blocking checkpoint proteins from binding with their partner proteins. This prevents the “off” signal from being sent, taking the brakes off the immune response and allowing the T cells to kill cancer cells.

Examples of ICIs include but are not limited to:

  • Pembrolizumab (Keytruda)

  • Atezolizumab (Tecentriq)

  • Nivolumab (Opdivo)

  • Ipilimumab (Yervoy)

  • Durvalumab (Imfinzi)

  • Avelumab (Bavencio)

Find out more about ICIs here. The Macmillan website is a valuable tool to look up specific therapies.

Which cancers may be treated with ICIs?

Immune checkpoint inhibitors have been approved for use in a range of cancer types, including: 

  • cancer

  • bladder cancer

  • cervical cancer

  • colon cancer

  • head and neck cancer

  • Hodgkin’s lymphoma

  • liver cancer

  • lung cancer

  • renal cell cancer (a type of kidney cancer)

  • skin cancer, including melanoma

  • stomach cancer

  • rectal cancer

  • any solid tumour that is not able to repair errors in its DNA that occur when the DNA is copied (these may have characteristics called mismatch repair deficiency or microsatellite instability-high)

What can you do next?

If you are being treated with one of the immune checkpoint inhibitors, try making the following changes to your lifestyle after checking with your medical team. You can share the paper link with them before your next appointment. 

  • Aim for a diverse colourful Mediterranean-style or other culturally appropriate anti-inflammatory diet with over 20g of fibre daily. This suggestion applies unless you have been told to deliberately restrict your fibre by your nutrition or medical team for specific reasons.

    • If you eat 6-7 portions of non-starchy vegetables daily and 1-2 portions of low sugar fruit, as well as switching from refined/white grains to wholegrains, you will easily hit this target. Try our Recipes section to help you incorporate more fibre. Do increase your intake gradually, so that your gut can get used to increased fibre intake. You can seek further advice from a specialist cancer nutrition team.

  • Aim for a minimum of 150 minutes of aerobic exercise at moderate intensity weekly. This can be 5 x 30 min sessions or longer sessions done less frequently. If you need further support, ask your medical team or seek out a cancer exercise specialist (e.g. CanRehab Trust) or specialist physiotherapist for further guidance. This is particularly important around surgery, when you have an increased risk of lymphoedema, during active treatment, with metastatic bone disease or in any situation that could compromise normal mobility and function.

  • Discuss vitamin D testing with your medical and/or integrative care team and follow their advice on replacement within safe levels.

  • Avoid medical cannabis use if you are on ICI therapy unless approved by your oncologist.

  • The research on probiotic/live biotherapeutic use is in its infancy, and we don’t currently have good commercial access to studied strains. Please note that any probiotic won’t do here and some probiotics may potentially affect ICI treatment in an undesirable way, so always seek professional advice. Watch this space as the research evolves and support your gut microbiota with excellent fibre intake and a varied, wholefood-based diet for now. You can discuss any further personalised guidance with your integrative oncology doctor or cancer nutrition specialist.

Any supplementation, including vitamin D, should be checked with your doctor or pharmacist to make sure there are no harmful interactions or contraindications to supplement use. Please do not discontinue or start any medications, including over-the-counter options, without checking with your medical team if you are on active cancer treatment.  

If you are under the clinic’s care, you may be offered assessment for systemic inflammation, vitamin D level testing or relevant gut microbiome profiling (as appropriate to the clinical situation), as well as support with nutrition, exercise and mind-body therapies, e.g. yoga therapy or EFT and emotional wellbeing coaching for stress management. We also have access to psycho-oncology support through our wonderful consultant psychiatrist for those who would like to have more in-depth therapy support around depression, anxiety, PTSD or managing their medications for these conditions.

Where do I find further information?

This information is provided for educational purposes only and is not a substitute for professional advice and medical care.

About the author

Dr Nina Fuller-Shavel is an award-winning Oxbridge-trained integrative medicine doctor, scientist, and educator with over a decade’s experience in integrative healthcare. Dr Fuller-Shavel is a Fellow of the College of Medicine, the British Association for Nutrition and Lifestyle Medicine (BANT) and the Royal Society of Arts (RSA). Dr Nina Fuller-Shavel was the Co-Chair of BSIO (British Society for Integrative Oncology) over 2021-2023 and now co-chairs the BSIO Education Committee. Dr Fuller-Shavel has obtained three Oxbridge degrees as a part of her scientific and medical training. Alongside this, Dr Nina Fuller-Shavel holds multiple qualifications in nutrition, integrative medicine, functional medicine, health coaching, herbal medicine, Traditional Chinese Medicine (TCM), yoga, mindfulness, and other therapeutic approaches. Dr Fuller-Shavel is a co-author of ‘Integrative Oncology in Breast Cancer Care’ with Dr Penny Kechagioglou, a book for healthcare professionals due to be published in 2024. 

Dr Nina Fuller-Shavel is the founder and Director of Synthesis Clinic, an award-winning multidisciplinary practice in the UK, specialising in women’s health and integrative cancer care. Alongside her clinical work, Dr Fuller-Shavel delivers educational programmes, participates in research in integrative medicine and precision health and contributes to scientific journal editorial boards and guideline development panels nationally and internationally. Finally, Dr Fuller-Shavel is the Co-Founder and Director of Oncio CIC, an innovative non-profit aimed at providing high quality app-based resources for people affected by cancer.

Nina Fuller-Shavel
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