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