Hakim, a 77-year-old physician board-certified in internal medicine, had been diagnosed with extensive small-cell lung cancer (SCLC). His functional level was impaired, and he was confined to a wheelchair (Karnofsky Performance Status Scale 3). High-dose corticosteroid therapy was initiated, with improved function, upon which chemotherapy (carbo/etoposide) was followed. He developed severe and debilitating symptoms which included fatigue, a persistent dry cough, disturbed sense of taste and reduced appetite. Despite his condition he kept an optimistic perspective. His oncology nurse referred him to our integrative oncology program (IOP), situated in a community-based oncology day-care service in Haifa, northern Israel. The IOP treats patients with chemotherapy-induced symptoms without charge, offering them complementary and integrative medicine (CIM) therapies. These are provided by a multidisciplinary team of physicians, nurses and practitioners with oncology-related CIM and supportive cancer care training. Patients referred by their oncology healthcare professional sit with the integrative physician (IP) and design a patient-tailored CIM treatment program. The IP provides up-to-date, evidence-based guidance on the potential benefits and risks of herbal medicine (e.g., herb-drug interactions).
During the initial IP consultation, Hakim described his health belief model and his expectations from the CIM treatments, addressing his list of concerns and symptoms related to the cancer and chemotherapy. He was open and direct, presenting his narrative and describing his experience of “being a patient”. His medical history included ischemic heart disease, and he had undergone 23 percutaneous coronary interventions and two bypass surgeries (CABG). He had developed chronic renal failure, with a serum creatinine of around 2.2 mg/dL. It was then that he “learned to be more accepting of death, whenever and at whatever age it may appear”. Hakim confided with the IP, telling him “I am taking chemotherapy only in order to improve my quality of life; If my family would not have insisted, I would most probably not have taken anything”.
Hakim was an Arabic- and Hebrew-speaking Israeli of Iranian descent, and was a follower of the Bahai religion for many years. His family encouraged him to “fight the cancer” through conventional means, including chemotherapy, while at the same time using traditional medicine, including herbal remedies. Hakim was especially interested in “Alanda” (Ephedra foeminea), a plant-derived remedy which was becoming increasingly popular among patients with cancer in Israel and the Palestinian Authority. A family member had gathered a large bunch of Alanda stalks and prepared an extract, this in order to “cure” Hakim’s cancer. As a conventional physician, Hakim wanted to hear from the IP about this herb, at least from a conventional medical perspective.
The IP suggested that they both search the medical literature (using the PubMed engine at the National Library of Medicine) for information on the effectiveness and safety of Alanda. The search emphasized safety-related issues, which addressed Hakim’s fear that Alanda would reduce the effectiveness of chemotherapy. The joint search did not find any information on the use of Alanda for cancer, or about its safety. Additional herbal products were also examined, with many exhibiting anti-cancer effects in laboratory studies, though their effectiveness and safety in the clinical setting remain unclear. The IP suggested focusing their efforts on reducing the symptom load, to which Hakim agreed. “Let us focus on my needs, rather than cancer cells”. This decision enabled them to co-define the CIM treatment goals, which addressed improving quality-of-life-related (QOL-related) concerns. These included fatigue, disturbed taste sensation and reduced appetite.
Over the next 6 weeks Hakim attended ten CIM sessions, despite the effort it took him to make the 45-minute drive from his home to the cancer center. He was always accompanied by a family member who had come to provide support. CIM modalities included acupuncture, guided imagery, anthroposophic music therapy, and advice on nutrition and herbal medicine. Symptom severity was monitored using the Edmonton Symptom Assessment Scale (1) and the Measure Yourself Concerns and Wellbeing (2) questionnaires, at baseline and at the end of treatments. A reduction in symptom severity was found for a number of symptoms, including taste, appetite, fatigue, and general well-being. Hakim wrote that “the treatments I was provided with helped reduce the side effects of chemotherapy, as well as with taste and appetite”. Hakim continued CIM treatments for another 9 months, and Alanda was not mentioned again. However, he continued to ask about other herbal products, and was offered evidence-based guidance regarding their effectiveness and safety.
The use of herbal medicinal remedies by patients with cancer presents a significant challenge to health care providers. Hakim shared a health belief model with many patients with cancer in Middle Eastern countries and other regions with a deep attachment to traditional herbal medicine. Patients invariably perceive these remedies as safe, supportive, and at times even “magical”, especially where conventional medicine fails. In a recent regional survey of 16 Middle-Eastern countries, 29 of the 44 herbs which were identified by 339 oncology health care providers have potentially harmful effects, including negative herb-drug interactions, direct toxic effects, and increased in vitro response of cancer cells to chemotherapy (3). The case of Hakim, a doctor who is also a patient, illustrates the fundamental role of the IP as a “gatekeeper”, providing an open and non-judgmental consultation on the effectiveness and risks of CIM treatments. The IP also serves a role as a “navigator” through the “stormy sea” of alternative medicine, in which there is a lack of a plausible or evidence-based rationale.
In the integrative oncology setting, IPs and other CIM practitioners serve an integral role in supportive and palliative oncology care. They provide patients with an additional perspective, as well as practical tools with which to maneuver through the often confusing maze of alternative therapies. Both supportive/palliative care and CIM share a common value in patient-centered care, as well as the need for a holistic and bio-psycho-social-cultural-spiritual perspective. The case of Hakim emphasizes the need for collaboration between these two domains, employing a multi-disciplinary team approach and addressing the varying expectations, needs, and health belief models of patients and their caregivers.
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Oldenmenger WH, de Raaf PJ, de Klerk C, et al. Cut points on 0-10 numeric rating scales for symptoms included in the Edmonton Symptom Assessment Scale in cancer patients: a systematic review. J Pain Symptom Manage 2013;45:1083-93. [Crossref] [PubMed]
- Paterson C, Thomas K, Manasse A, et al. Measure Yourself Concerns and Wellbeing (MYCaW): an individualised questionnaire for evaluating outcome in cancer support care that includes complementary therapies. Complement Ther Med 2007;15:38-45. [Crossref] [PubMed]
- 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 2016;122:598-610. [Crossref] [PubMed]