Integrative Oncology ProgramLin Medical Center
Rappaport Faculty of Medicine Technion-Israel Institute of Technology
Clalit Health ServicesHaifa Israel
Nile
EuphratesTigris
Cancer-related CIM use in the Middle-East
Turkey 40-70%
Iran 35%Jordan 35%Israel
50%
Invasive breast cancer in IsraelAge adjusted incidence rate, 1990-2006
Female Jews
Female Arabs
Haifa
medicine and cancer
Disclosure
medicine and
And
Within
Health-belief
OrOpenness
Relatedness
Concerns expected to be improved by integrative CM treatment
0
10
20
30
40
50
60
70
GI concerns Fatigue Pain Sleep Functioning
63,2
51,9
40,5
24,4
16,7
% of patients
reporting concern
Ben-Arye E, Massalha E, Bar-Sela G, SilbermannM, Agbarya A, Saad B, Lev E, Schiff E.
Stepping from traditional to integrative medicine: perspectives of Israeli-Arab patients on complementary medicine's role in cancer care. Annals of Oncology 2014
67,9
39,5
34,3
1,5 0,9
5,6
63,2
40,5
51,9
15,9
24,4
16,7
0
10
20
30
40
50
60
70
80
90
100
GI symptoms Pain Fatigue Emotional Sleep Dailyfunctioning
Palestinians Israeli-Arabs
P<0.001
P=0.86
P=0.25
%
Ben-Arye E, Hamadeh AM, Schiff E, Jamous RM, Dagash J, Jamous RM, Agbarya A, Bar-Sela G, Massalha E,
Silbermann M, Ali-Shtayeh MS. Compared Perspectives of Arab Patients in Palestine and Israel on the Role of
Complementary Medicine in Cancer Care. J Pain Symptom Manage 2014
P<0.001
P<0.001
P<0.001
5,695,81 5,81 5,68
5,195,04
4,67
5,25
5,525,34
5,81
4,16
5,62
4,56
0
1
2
3
4
5
6
7
Jews
Arabs
Patients' expectations of CTM consultation if integrated within oncology care [Scores are rated on a 1 (low agreement) to 7 scale (high agreement).]
p<0.0001 p=0.005 p<0.0001 p<0.0001 p<0.0001p=0.23 p=0.61
Rabbi Hayim Vital (17th cent.)Suppresses tumor progression
by modulating angiogenesis
Apoptosis inductionAnti-emesis
Bedouin traditional med Modified citrus pectin - PSA
al–Kindī (9th cent.)Growth inhibition of colorectal cancer cells – Pancreatic CAA
Lemon
GingerTurmeric
Cinnamon
Middle-East Cancer Consortium workshop on Integrative
Medicine in Cancer Care in the Middle East Cyprus, 2010
MERGIOMiddle-East Research Group
in Integrative Oncology
19 Clinical trialsHerbal medicine
Henna (Lawsonia inermis)Hand foot syndromeYucel, Turkey 2008
Yucel, Turkey, 2008
HoneyMucositis in head/neck cancer
Rashad, Egypt 2008Motallebnejad, Iran 2008
Wheat grass juice(Triticum aestivum )Hematological toxicity
in breast cancerBar-Sela, Israel 2007
HESA-AAdvanced cancer
Ahmadi, Iran 2005, 2005, 2009, 2010
Mistletoe(Viscum Album)Advanced cancer
Mabed, Egypt 2004Bar-Sela, Israel 2004, 2006
Clinical trials
Kefir supplementation
Colorectal cancerCan, Turkey 2009
Yucel, Turkey, 2008
HomeopathyTraumeel-S
Stomatitis in hemato-oncology
Oberbaum, Israel 2001
Tomato lycopene Colon cancer
Walfisch, Israel 2007
SupplementsNutrition
Clinical trialsYucel, Turkey, 2008
AnthroposophicArt therapy
Fatigue depression Bar-Sela, Israel 2007
Progressive Muscle Relaxation Guided Imagery
Baider, Israel 1994, 2001
HypnosisXerostomia in
head / neck cancer Schiff, Israel 2009
Mind bodyspirit
Yoga Breast cancerUlger, Turkey 2010
Herbal use by patients referred to integrative oncology consultation
during chemotherapy in northern IsraelAlmog et al. Support Care in Cancer 2014
Documentation of herbal use during IP consultation
50% of patients
86 individual herbs30 herbal formulas
The Middle-East as a botanical garden
Identified themes
Barriers outside the hospital:
• Public unawareness of CTM risks & overstated effectiveness claims
• Lack of CTM legislation
HCP-patient communication
barriers• Non-disclosure of CTM use
induced by judgmental HCP’s attitude or patient’s concern to reveal non-conventional use
• Failure to establish realistic expectations of CTM objectives
• HCP’s difficulty respecting patient’s CTM-related health belief model
• Unmatched awareness of CTM risks (e.g. herb-chemotherapy interactions)
• Consultation re CTM modalities with limited research evidence
Patient & caregiver related
barriers• Lack of knowledge• Unrealistic expectations
of CTM effectiveness• Unawareness of CTM
risks• Gaps between EBM
and charlatanry
HCP-related barriers
• Lack of knowledge on CTM research findings
• Lack of training in CTM consultation
• HCPs skeptical attitude
Communication and integration: a qualitative analysis of perspectives among Middle Eastern oncology healthcare professionals on the integration of complementary medicine in supportive cancer care. – Ben-Arye et Al. JCRCO 2016
Ben-Arye E, Samuels N, Goldstein LH et al. Potential risks associated with traditional herbal medicine use in cancer care: A study of Middle-
Eastern oncology health care professionals
Cancer 2015
Safety concerns 29 / 44 herbs
Potential herb-drug interactions (15)
Potential toxic effects (18)
Increased chemosensitivity of cancer cells (7)
ConclusionsThe presence of integrative physicians with training in complementary and traditional medicine can help patients and their HCPs
reach an informed decision regarding the safety and effective use of these products
The Middle-East as a non-judgmental
integrative oncology consultation model
Acre
Tiberias
Nazareth
Jenin
Haifa
0
11
1
1
2
2
33
3
3
3
3
3
1
2
2
Female Male Muslim Christian Jewish Druze Baha'i
Patient zero
1Ephedra users10-12/2013
2Ephedra users1-4/2014
3Ephedra userssince 5/2014
Hadera
Sea
Of
Galilee
Mediterranean
Haifa bay
Shfaram
Daliatel Carmel
2
Ben-Arye, Mahajna, Radi, Ali-Shtayeh, Bentur, Lev, Deng, Samuels .Exploring an herbal "wonder cure" for cancer: a multidisciplinary approach.
Cancer Res Clin Oncol. 2016 Germany Cancer Society
Step 1: Prevalence of Alanda Use
Step 3: Assessing effectiveness(QOL-related)
Step 2: Assessing expectations and health- belief model
Step 4: Assessing risks (toxicity, interactions)
Step 5: Recommendations (tentative)
Patient Oncologist Integrative Physician Researcher
Alanda◊ Medical History
(non-judgmental)◊ Referral to Integrative
Physician (IP)
◊ Identify herbals(quantity/quality of active ingredients)
◊ Discuss expectations• QOL-related
(vs. cancer cure)• Treatment outcomes
◊ Botanical classification◊ Basic science tests: • Identify components• HPLC
◊ Medical Historian• Identify past use• Search for benefit◊ Herbalist
◊ Literature search(PubMed, etc.)
◊ Patient-tailored CIM • address concerns• QOL-related outcomes• monitoring
◊ Basic scientist• XTT assays, etc.◊ Toxicologist• Contamination◊ Pharmacologist* herb-drug interactions
◊ Safety profile(tentative)
◊ Regular monitoring
◊ Patient-tailored • address concerns• QOL-related outcomes• monitoring
N a u s e a
F a t i g u e
XTT
◊ EBM recommendation◊ Co-design of CIM Tx◊ F/U and monitoringOncologist
IP
Patient
Approach to establishing evidence-based guidance for the use of herbs during chemotherapy – Ben-Arye et Al. JCRCO 2016
סיכון
שרלטנות
Cancer as a journeyof disintegration
Bio
Psycho
Social
Spiritual
CAM
Integrating
Doingand
Being
Symptom-basedpain fatigue nausea
sleep anxiety dyspnea
QOL
I
Now-ness
Salma a 36-year-old single woman
Diagnosis:
Lt. Breast CA stage IIIa T3N2M0ER positive PR negative HER-2 negative (FISH)
Presenting symptom: Left shoulder pain (1 year)
Treatment:
2/2011 Chemo: ACX4 Neo-adjuvant minimal response
4/2012:
4/2011 PET CT: extensive adenopathy (including mediastinum)
Tx: Zoladex + Tamoxifen
2/2012 Increased markers PET CT: mets Rt. adrenal Chemo: Taxol
Patient’s expectations: Advise on food
Patient’s previous CAM use: Traditional Arab herbs
Specific CAM use for cancer: Arum Palestinum
Traditional Arab practitioner provided cupping and blood letting
Lifestyle:Dislikes herbs; no smoking
Overweight minimal physical activity
Salma’s main concerns:
Psycho-social-spiritual aspects: Never married, lives with parents. Studied in Islamic religious college
Escorted by her sister
Has 6 siblings
Loss of 2 sisters
Deep religious faith: “I am not miserable as a
result of my cancer,
God loves me.”
Integrative treatment goals:
Initial IM treatment plan
Referral to social-worker
Referral to integrative clinical dietitian
Scheduling acupuncture
& manual Chinese treatment
Considering herbs and yogurt
to improve diarrhea and nausea
Communication
Documentation
Oncologist
Nurse oncologist
Social worker
Family practitioner
Salma’s integrative treatment program
Herbal & nutritional
counseling Integrative physician
Clinical dietitian
5 sessions
Wheatgrass juice
Nigella sativa
Acupuncture
9 sessions
Manual
healing
16 sessions
0
1
2
3
4
5
6
7
8
9
10
Pain Fatigue Nausea Depression Anxiety Drowsiness Dyspnea Appetite Sleep Well-B
Taxol 8 Taxol 19
Patient’s narrative: “The treatment provided by Bella (integrative nurse)
significantly helps me. It gives me “fuel”. I return home as new,
going around with no nausea and diarrhea”.
0
1
2
3
4
5
6
Mood Fatigue Well-being
Mycaw Taxol 8
Mycaw Taxol19
0
8
16
24
32
40
48
Sp-12 Meaning/Peace Faith
Taxol 8
Taxol 19
Clinical assessment - Salma
Integrative physician assessment: Along the first 9 weekly sessions, improvement
was documented concerning patient’s emotional stress, fatigue, nausea, appetite, neuropathy in left arm, and general well-being.Acupuncture is indicated more often to improve neuropathy in legs.
Oncologist assessment:CIM contribution to patient’s well-being: 5/7
Oncologist-integrative physician communication: 5/7
Treatment: 7/2012 Taxol is due to neurotoxicityNLF is started: NAVELBINE/ LEUCOVORIN /5 F-U
8/2012 Difficulty in eating; Rt. leg weaknessMRI: metastases in brain: Brain irradiation10/2012 Brain and meningeal metastatic spreadDexacort + Oral VP-16
28 October 2012
Salma came with her sister into our clinic in a wheelchair during Eid al-Adha األضحىعيد (Feast of the Sacrifice)
Salma was
gradually feeling
pain relief as we
applied acupuncture
and gentle touch
At the conclusion of
the session, Salma
insisted to stand on
her feet… and smiled
Middle-Eastern integrative oncology research
Top Related