Meet the Practitioner: Dr. Diljeet Singh

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Listen to the full conversation with Dr. Diljeet Singh, an integrative gynecologic oncologist, and Christine Mineart, program director of CancerChoices. They discuss health insurance challenges, cancer and exercise research, navigating integrative cancer care, and tips for finding moments of mindfulness. Many additional gems can be found within the podcast including practical guidance for both people with cancer and inspiration for health professionals interested in exploring integrative oncology

Explore several highlights from this podcast conversation.

How would you define the terms used in integrative oncology (complementary, integrative, alternative)? 

For a long time, we’ve used terms like “alternative” or “complementary” treatments in medicine. “Complementary” suggested something additional, like steak sauce to a steak—nice but not essential. “Alternative,” on the other hand, often had a negative connotation, implying a rejection of traditional care. These terms can be problematic: one underestimates the value of non-traditional tools, and the other devalues Western care. Integrative oncology, to me, means truly considering the whole person and using every necessary tool to help them. 

Traditional oncology often focuses narrowly on curing cancer, sometimes at the expense of quality of life and other patient goals. Integrative medicine looks at the whole person and uses all available tools wisely and with open minds.. For example, nutrient-dense food might be as crucial to recovery after surgery as perioperative antibiotics. We used to restrict activity after surgery, thinking it would disrupt healing, but now we know early activity improves recovery. There’s substantial evidence, including meta-analyses and systematic reviews, showing that physical activity post-diagnosis can improve cancer survival rates by up to 30%. So, when I talk about integrative oncology, I mean considering the whole person—their life goals, health, genetics—in the context of our environments and using all available resources to support them.

We’ve discussed that therapies like yoga and acupuncture have plenty of evidence, are proven to be safe, and have demonstrated effects. Do you have insights into why such therapies aren’t covered by health insurance?

It’s a complex issue rooted in our profit-driven healthcare system. I spend a lot of my time advocating for Medicare Advantage companies to cover essential care and to stop requiring pre-authorizations for routine cancer staging tests, which often cause delays. The reason therapies like yoga and acupuncture aren’t covered, despite being safe and evidence-based, is tied to the profit motive. Health care and insurance have become profit-driven endeavors, which has fundamentally changed how care is provided.

There’s no good reason these therapies aren’t covered. It’s part of a broader issue where insurance companies deny coverage for various treatments, not just complementary therapies, to maximize their profits. They often deny necessary treatments like CT scans, chemotherapy, physical therapy, or rehabilitation. Denying coverage is a way for them to make more money. In spite of NCCN recommendations which include yoga as an option for fatigue this has not been considered “standard therapy” and so it is not covered.  We need to include these therapies in our advocacy efforts and push health care insurers to cover all therapies that show effectiveness. 

How can patients advocate for themselves when faced with health insurance coverage challenges?

When someone has cancer, even making a simple phone call can be overwhelming. While many patients do advocate for themselves, it’s often a daunting task. Fortunately, most larger oncology offices have adapted to support patients in this area. In many practices I’ve worked with, we had more billing clerks than chemo nurses. These billing staff members assist with pre-authorizations, handle denials, and guide patients through the process, such as instructing them on which numbers to call and options to select.

This is an area where resources are often wasted. Ideally, these staff members would spend their time caring for patients rather than negotiating with insurance companies. It’s a significant issue—some statistics suggest that up to 20 million hours of doctor- office time, including time spent by the entire office staff, are wasted annually on obtaining pre-authorizations and challenging denials.

Many patients feel hopeless, particularly when it comes to integrative therapies, but this also applies to standard treatments. Few people challenge denials because it can be extremely difficult, especially in rural areas where doctors may not have the same level of staff support. However, of the denials that are challenged, around 70-80% are eventually reversed, indicating that there often isn’t a valid medical reason for the denial—insurers count on the fact that not all patients will push back and so they can avoid paying. Patients can advocate for themselves by being persistent and enlisting the help of their oncology office’s billing staff. Understanding that challenging denials can lead to reversals can also empower patients to push through the bureaucratic obstacles.

What are the barriers that you see come up for patients who are pursuing integrative care, and oncologists who are wanting to collaborate with their patients?

There are several barriers. Firstly, the healthcare system itself presents challenges, both financially and in terms of time. Many patients don’t have enough time with their doctors during visits. This lack of time limits doctors from thoroughly discussing integrative options. Additionally, many doctors are not trained in integrative medicine and may not be familiar with the available options. Their primary concern is to avoid possible  harm or complications, so they might advise against therapies they don’t fully understand to prevent potential interactions with standard  treatments like chemotherapy or radiation.

Moreover, the knowledge gap is significant. Some supplements and herbs can indeed have side effects or interfere with treatments. For example, large doses of fish oil can make platinum chemotherapy less effective, and certain vitamins can reduce the effectiveness of radiation. While doctors are right to be cautious, not all have the expertise to navigate these integrative options.

However, this is changing. Many medical schools now have departments of integrative medicine and offer fellowships in the field. Patients interested in integrative care should seek out integrative practitioners who have a balanced approach and understand the importance of using every available tool, rather than dismissing conventional treatments.

In academic centers, natural collaborations often occur because doctors have opportunities to work together. For example, an oncologist might collaborate with a naturopath they trust or consult a pharmacist who can review and ensure the safety of integrative treatments. If patients live in areas without such resources, they can seek a second opinion from an academic center and establish an ongoing collaboration.

Patients should communicate openly with their oncologists about their interest in integrative options. Utilizing patient portals to send detailed messages before appointments can help doctors prepare and provide more thoughtful responses. Nurses and assistants can also be valuable points of contact for discussing integrative care.

For those in rural areas, telehealth can be a viable option. Patients can connect with specialists at major centers and collaborate with their local oncologists to implement integrative treatment plans. This approach has been successful for many, providing access to expert care despite geographical limitations. While telehealth requires practitioners to be licensed in the same state as the patient, this is often manageable.

Overall, patients and oncologists need to work together, leveraging available resources and expertise, to pursue integrative care effectively.

Can you share an example of when you have seen a person with cancer tap into their inner wisdom? 

When navigating cancer, I’ve seen many patients tap into their inner wisdom. They often face overwhelming amounts of information and pressure from family and friends, making it crucial to tune into their own capabilities and beliefs. It’s important for them to consider what they trust will help, and what aligns with their personal goals.

Take treatments like surgery for ovarian cancer, for instance. Surgery can significantly improve chances of cure, extend remission, and enhance long-term quality of life. However, it also comes with short-term risks, including pain and complications. Patients must weigh these risks against the benefits, just as they do with integrative therapies like Reiki or yoga. Although these modalities may lack extensive clinical trials due to lack of funding, their risks are minimal compared to their potential benefits. Even chemotherapy, which is often very effective, comes with significant toxicity and long recovery times. Balancing the risks and benefits of all treatments, whether conventional or integrative, is a form of common sense and self-knowledge that patients should trust.

Patients should communicate openly with their healthcare providers, use patient portals for detailed pre-visit questions, and consider second opinions or telehealth consultations to access integrative care options. Tapping into their inner wisdom and common sense can empower them to make informed decisions that support their overall well-being on their cancer journey.

At CancerChoices we have a strong focus on healing. From your practice or in your own life, what does healing mean to you? 

When thinking about healing, it’s important to recognize that it’s not always about achieving a cure. While cure is a goal I commit to with every patient who desires it, healing can take on different forms. For some patients, healing means managing symptoms effectively. For others, it’s about being able to attend a significant event, like a daughter’s wedding, or simply understanding what is happening to their body. Ultimately, healing is about providing the best quality of life possible within the context of what matters most to the patient.

When I think about healing in the context of a cancer journey, I consider the patient’s goals, both short-term and long-term. Some refer to these as “soul goals,” but regardless of the terminology, it’s about understanding and working towards what truly matters to you. This approach involves constantly revisiting and reassessing these goals. For example, while studies might suggest six treatments, individual needs can vary, and sometimes fewer treatments may suffice.

Healing, then, is about helping patients achieve their goals and providing the best quality of life as defined by them. It involves letting go of regrets and focusing on the present and future. Research has shown that post-diagnosis physical activity is a strong predictor of better outcomes, emphasizing that what patients do after diagnosis is crucial.

If I could encourage patients to let go of the “what ifs” and focus on taking care of themselves now, I would feel like I’ve made a significant impact on their healing journey.

Dr. Singh’s Bio

Diljeet K. Singh is a women’s health advocate and an integrative gynecologic oncologist currently based in Washington DC. Dr. Singh received her medical degree from Northwestern University and master’s degree from the Harvard School of Public Health. She completed an obstetrics and gynecology residency at the Johns Hopkins Hospital and a gynecologic oncology fellowship at the MD Anderson Cancer Center. She completed her doctoral degree in public health on cost analysis at the University of Texas School of Public Health and an associate fellowship in integrative medicine at the University of Arizona. She is a long time member of the advisory board for FORCE Facing Hereditary Cancer Empowered and the President-Elect of Physicians for a National Health Program.

Resources mentioned in the podcast

• Dr. Andy Weil demonstrating the 4-7-8 breath ›
• ACS Commission on Cancer: site directory ›
• CancerChoices: Moving More ›
• Guided Imagery › with Belleruth Naparstak
• Research on physical activity and cancer mortality: Friedenreich CM, Stone CR, Cheung WY, Hayes SC. Physical activity and mortality in cancer survivors: a systematic review and meta-analysis. JNCI Cancer Spectrum. 2019 Oct 17;4(1).
• Research on lifestyle and breast cancer survival: Parada H Jr, Sun X, Tse CK, Olshan AF, Troester MA. Lifestyle patterns and survival following breast cancer in the Carolina Breast Cancer Study. Epidemiology. 2019 Jan;30(1):83-92.
• PNHP Profits Over Patients report ›
• PNHP Taking Advantage report ›