Perceptions of complementary medicine integration in supportive cancer care of Arabs and Jews in Israel: a cross-cultural study

Identifying Factors Associated With Disparities in Access to Integrative Oncology Program

CONTEXT AND OBJECTIVES

Cancer centers are increasingly providing complementary medicine as part of an emerging discipline termed 'integrative oncology' (IO). The present study explored factors associated with disparities in referral and adherence to a freely-provided IO program.

METHODS

The databases of three oncology centers in northern Israel were searched retrospectively for chemotherapy-treated oncology patients eligible for referral by their oncology healthcare professionals to an integrative physician (IP) consultation. Demographic and cancer-related variables associated with the referral, and attendance by patients at the consultation were identified, as was adherence to the 6-week IO treatment program (high adherence, attending ≥4 IO treatment sessions; low adherence, 0-3 sessions).

RESULTS

Of 4988 eligible patients, 1694 (34%) were referred to the IP consultation, with 1331 (78.6%) attending the consultation of which 766 (57.6%) were adherent to IO treatments. Multivariate analysis revealed lower referral rates among patients speaking primarily Arabic and Russian vs. Hebrew (OR = 3.0, 95% CI = 2.0-4.6, P < 0.0001); males vs. females (OR = 1.94, CI = 1.3-2.9, P = 0.001); those not reporting emotional distress (OR = 1.5, CI = 1.02-2.16, P = 0.037); and older age (OR = 1.04, CI = 1.03-1.06, P < 0.0001). Arabic and Russian-speaking patients were less likely to adhere to IO treatments (OR = 0.52, 95% CI = 0.32-0.83, P = 0.006).

CONCLUSION

Patients' ethno-national origin and immigration status (primary language, Arabic and Russian), male gender and older age were associated with lower rates of referral to and attendance of the IP consultation, with reduced adherence to weekly IO treatments. These findings require further study to identify barriers toward diversity, equity and inclusion in IO care, increasing awareness among healthcare professionals regarding the benefits of these services for improving patient wellbeing.

Exploring unmet concerns in home hospice cancer care: Perspectives of patients, informal caregivers, palliative care providers, and family physicians

OBJECTIVES

The study examines perspectives of patients in home hospice care; their informal caregivers; palliative health-care providers (HCPs); and family physicians, all regarding patients' unmet needs and quality of life (QoL)-related concerns.

METHODS

Participants from all 4 groups were approached within 2 months after the patient's admission to the home hospice care unit. Participants completed Edmonton Symptom Assessment Scale (ESAS) and Measure Yourself Concerns and Wellbeing (MYCAW) questionnaires, for patient's QoL-related concerns. Qualitative analysis of short narratives was conducted using ATLAS.ti software for systematic coding.

RESULTS

In total, 78 participants completed the study questionnaires: 24 patients, 22 informal caregivers, 22 palliative HCPs, and 11 family physicians. Informal caregivers gave higher scores (i.e., greater severity) than patients for fatigue on ESAS (p = 0.009); and family physicians lower scores than patients for ESAS drowsiness (p = 0.046). Compared with patients, palliative HCPs gave higher scores for patient emotional-spiritual concerns (77.2% vs. 41.7%, p = 0.02); lower scores for gastrointestinal concerns (p = 0.048); and higher scores for overall function (p = 0.049). Qualitative assessment identified a gap between how patients/informal caregivers vs. palliative HCPs/family physicians regard emotional-spiritual themes, including discussing issues related to death and dying.

SIGNIFICANCE OF RESULTS

The findings of the present study suggest that exploring a multifaceted cohort of home hospice patients, informal caregivers, palliative HCPs, and family physicians may provide insight on how to reduce communication gaps and address unmet needs of patients, particularly regarding emotional and spiritual concerns.

CONCLUSIONS

While the 4 groups were similar in their scoring of patient QoL-related concerns, there were discrepancies for some concerns (e.g., patient fatigue) and expectations regarding the need to discuss emotional and spiritual concerns, including on death and dying. Educational initiatives with programs providing training to all 4 groups may help bridge this gap, creating a more open and collaborative hospice care environment.

Experience of patients with breast cancer with traditional treatment and healers' understanding of causes and manifestations of breast cancer in North Shewa zone, Ethiopia: a phenomenological study

OBJECTIVES

Despite a high number of traditional healers (THs) who treat patients with cancer in Ethiopia, there is limited evidence that explored the lived experience of patients with breast cancer (BC) with traditional treatment and healers' understanding of the causes and manifestations of BC.

DESIGN

A phenomenological study design was employed.

SETTING

This study was conducted in the North Shewa zone in Ethiopia.

PARTICIPANTS

Eight in-depth interviews were conducted; four of which were with patients with BC and four with THs. Semistructured interviewing techniques were used to collect data from the two groups of respondents. All interviews were audio-recorded. The recorded data were transcribed verbatim. Coding and marking were then performed to make the raw data sortable. The marked codes were then summarised and categorised into themes.

RESULTS

In this study, some of THs were unaware of the main risk factors or causes of BC. They did not mention the lifestyle risk factors of BC such as smoking cigarettes, consuming alcohol and eating habits. The most common clinical manifestations noted by THs were lumps at the breast, discharge from the nipples and weakness. All of the THs got their knowledge of BC treatment from their families and through experience. Regarding the lived experience of treatment, some patients with BC perceived that traditional medicines were safer and more effective than modern treatments and they eventually referred themselves to the THs.

CONCLUSIONS

Although THs were unaware of the causes of BC, they were familiar with basic signs and symptoms of the disease. Patients with BC referred themselves to the THs because they preferred traditional therapies to modern ones. In order to better satisfy the unmet needs of Ethiopian women with BC, due consideration should be given to traditional treatments.

Expectations of Patients and Their Informal Caregivers from an Integrative Oncology Consultation

Integrative physicians (IPs) working in supportive and palliative care are often consulted about the use of herbal medicine for disease-related outcomes. We examined 150 electronic files of oncology patients referred to an IP consultation for demographic and cancer-related data; use of herbal medicine for disease-related outcomes; and narratives of patients and informal caregivers describing their expectations from the IP consultation. Over half (51.3%) of patients reported using herbal medicine for disease-related outcomes, more so among those adopting dietary changes for this goal (P < .005). Most (53.3%) were accompanied by an informal caregiver, especially those using herbal medicine (66.2%, P = .002) or adopting dietary changes (69.8%, P < .001). The majority of patients (84.4%) expected the IP to provide guidance on the use of herbal medicine for disease-related outcomes (e.g., "curing," "shrinking," "eradicating" and "cleansing"). Most caregivers (88.8%) expressed a similar expectation, with some having additional questions not mentioned by the patient. IPs need to identify and understand expectations of oncology patients and their informal caregivers, helping them make informed decisions on the effective and safe use of herbal medicine. The IP may need to "reframe" expectations regarding the ability of herbal medicine to treat cancer and immunity, to more realistic quality of life-focused goals.

Effects of a patient-tailored integrative oncology intervention in the relief of pain in palliative and supportive cancer care

CONTEXT AND OBJECTIVES

The present study examined the impact of an integrative oncology treatment program in the relief of pain in patients undergoing chemotherapy and/or palliative care.

METHODS

In this pragmatic prospective controlled study, patients undergoing chemotherapy and/or palliative care were referred by their oncology healthcare providers to an integrative physician (IP) consultation, followed by weekly integrative treatments. Patients attending ≥ 4 sessions during the first 6 weeks of the study were considered to be highly adherent to integrative care (AIC). Pain was assessed at baseline and at 6 and 12 weeks using the ESAS (Edmonton Symptom Assessment Scale) and EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) tools.

RESULTS

Of 815 eligible patients, 484 (59.4%) were high-AIC and 331 low-AIC. Mean pain scores decreased significantly from baseline to 6 and 12 weeks in both groups. However, ESAS and EORTC pain scores improved significantly more in the high-AIC group at 6 weeks (p= 0.008), though not at 12 weeks. Between-group analysis of participants undergoing adjuvant/neo-adjuvant chemotherapy showed higher pain reduction in the high-AIC group at 6 weeks (ESAS, p = 0.006; EORTC, p = 0.046), as was the case with patients receiving palliative care (ESAS p = 0.04; EORTC p = 0.056).

CONCLUSIONS

High adherence to integrative care was found to be associated with a greater effect on pain relief at 6 weeks but not at 12 weeks in patients undergoing chemotherapy and/or palliative care.

Exploring Herbal Medicine Use during Palliative Cancer Care: The Integrative Physician as a Facilitator of Pharmacist-Patient-Oncologist Communication

Oncology patients frequently use herbal and other forms of complementary medicine, often without the knowledge of oncologists, pharmacists, and other healthcare professionals responsible for their care. Oncology healthcare professionals may lack the knowledge needed to guide their patients on the safe and effective use of herbal medicinal products, a number of which have potentially harmful effects, which include direct toxicity and negative herb–drug interactions. The current review addresses the prevalence and expectations of oncology patients from herbal medicine, as well as evidence for the beneficial or harmful effects of this practice (potential and actual), especially when the herbal products are used in conjunction with anticancer agents. Models of integrative oncology care are described, in which open and effective communication among oncologists, pharmacists, and integrative physicians on the use of herbal medicine by their patients occurs. This collaboration provides patients with a nonjudgmental and multidisciplinary approach to integrative medicine, echoing their own health-belief models of care during conventional cancer treatments. The role of the integrative physician is to facilitate this process, working with oncologists and pharmacists in the fostering of patient-centered palliative care, while ensuring a safe and effective treatment environment. Case scenario: W. is a 56 year old female artist who was recently diagnosed with localized hormone receptor-positive breast cancer. Following lumpectomy and sentinel node dissection, she is scheduled to begin adjuvant chemotherapy with a regimen which will include adriamycin, cyclophosphamide, and paclitaxel (AC-T protocol). She is worried about developing peripheral neuropathy and its impact on her ability to paint, and she asks about a number of dietary supplements which she heard could prevent this from happening: omega-3, vitamin E, alpha-lipoic acid, and acetyl-l-carnithine. She is concerned, however, that the supplements may negatively interact with her chemotherapy regimen.

Integrative Oncology in Supportive Cancer Care in Israel

Purpose: Integrative oncology (IO) services provide complementary/integrative medicine (CIM) therapies to patients as part of their supportive cancer care. In this study, we examine and compare the structural, operational, financial and academic/research-related aspects of IO services in Israeli oncology centers. Methods: The medical directors of seven Israeli IO programs completed questionnaires which explored the objectives and organizational features of their service within the context of supportive cancer care. Results: All participating IO services addressed patient-reported concerns related to quality of life and function, within the context of conventional supportive cancer care. The centers shared similar characteristics regarding the procedure of referral to their service and emphasized research and teaching initiatives within an academic framework, as part of their clinical practice. A number of obstacles to integration were identified, primarily those related to financial considerations, such as the need for patients to carry the cost of the CIM treatments. Conclusions: IO services situated within conventional oncology departments in Israel share a number of characteristics, as well as obstacles to their incorporation into standard care. All participating centers described both clinical and academic activities, including research initiatives and the promotion of CIM in an academic setting. Further research is needed in order to better understand the place of CIM in the oncology setting and prioritize the allocation of resources in order to advance the inclusion of CIM in standard supportive cancer care.

Impact of a patient-tailored complementary/integrative medicine programme on disturbed sleep quality among patients undergoing chemotherapy

OBJECTIVES

The present study examined the impact of a patient-tailored complementary/integrative medicine (CIM) programme on sleep quality in patients undergoing chemotherapy for breast and gynaecological cancer.

METHODS

Study participants received standard supportive care, with or without weekly CIM treatments. Disturbed sleep quality was defined as a score of ≥4 on the Edmonton Symptom Assessment Scale (ESAS) or a score of ≥3 on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). Adherence to integrative care was defined as attending ≥4 CIM treatments, with ≤30 days between each session.

RESULTS

Of 388 eligible patients, 264 (68%) reported disturbed sleep quality. Baseline-to-follow up assessment (at 6 weeks) was optimal for 104 patients in the treatment group and for 76 controls, with 75 of treated patients found to be adherent to the CIM intervention. Sleep-related ESAS scores improved more significantly in treated patients (p=0.008), as did sleep-related concerns on EORTC (treatment group, p=0.026).

CONCLUSIONS

A patient-tailored CIM programme may improve sleep quality and related concerns among patients with breast and gynaecological cancer undergoing chemotherapy. Further research is needed to better understand the impact of CIM on sleep quality in this patient population.

TRIAL REGISTRATION NUMBER

NCT01860365.

Mind the gap: Disclosure of dietary supplement use to hospital and family physicians

OBJECTIVE

We aim to compare patients' perspectives on communication with their hospital physicians (HPs) and primary care physicians (PCPs) on patients' dietary and herbal supplements (DHS) use.

METHODS

We conducted a cross-sectional prospective study among in-patients using structured questionnaires on DHS use. Multivariate logistic regression models assessed variables influencing doctor-related reasons for patients' nondisclosure of supplement use.

RESULTS

Of 452 DHS users identified, 133 (29.4%) used herbs and 319 (70.6%) used non-herbal supplements. DHS users reported that PCPs were more aware of DHS consumption than HPs (70.1% vs. 34.1%, P<0.0001). PCPs initiative to detect supplement use was higher compared with HPs (P<0.0001). Doctor-related reasons for non-disclosure of DHS use were more prominent in a hospital setting. Multivariate logistic regression model suggested association between older patient age and doctor-related non-disclosure (p=0.03). DHS use was recorded in only 33 patients medical files.

CONCLUSIONS

Doctor-patient communication concerning DHS use is significantly poorer during hospitalization compared with primary-care settings. A significant barrier for in-hospital disclosure is doctor-related.

PRACTICE IMPLICATIONS

Continuity of care between community and hospital physicians regarding patients' DHS use should be improved due to the safety implications of such use. Educating physicians on DHS and improving communication could bridge this gap.

Quality of life-related outcomes from a patient-tailored integrative medicine program: experience of Russian-speaking patients with cancer in Israel

OBJECTIVE

Complementary/integrative medicine (CIM) is increasingly being integrated with standard supportive cancer care. The effects of CIM on quality of life (QOL) during chemotherapy need to be examined in varied socio-cultural settings. We purpose to explore the impact of CIM on QOL-related outcomes among Russian-speaking (RS) patients with cancer.

PATIENTS AND METHODS

RS patients undergoing chemotherapy receiving standard supportive care were eligible. Patients in the treatment arm were seen by an integrative physician (IP) and treated within a patient-tailored CIM program. Symptoms and QOL were assessed at baseline, at 6, and at 12 weeks with the Edmonton Symptom Assessment Scale (ESAS), the Measure Yourself Concerns and Wellbeing (MYCAW) questionnaire, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30).

RESULTS

Of 70 patients referred to the treatment arm, 50 (71.4 %) underwent IP assessment and CIM treatments. Of 51 referred to the control arm, 38 (76 %) agreed to participate. At 6 weeks, CIM-treated patients reported improved ESAS scores for fatigue (P = 0.01), depression (P = 0.048), appetite (P = 0.008), sleep (P < 0.0001), and general wellbeing (P = 0.004). No improvement was observed among controls. Between-group analysis found CIM-treated patients had improved sleep scores on ESAS (P = 0.019) and EORTC (P = 0.007) at 6 weeks. Social functioning improved between 6 and 12 weeks (EORTC, P = 0.02), and global health status/QOL scale from baseline to 12 weeks (EORTC, P = 0.007).

CONCLUSION

A patient-tailored CIM treatment program may improve QOL-related outcomes among RS patients undergoing chemotherapy. Integrating CIM in conventional supportive care needs to address cross-cultural aspects of care.

TRIAL REGISTRATION

The study protocol was registered at ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT01860365 ).