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The interplay between complementary medicine and palliative care, both of which emphasize a patient-centered approach in order to improve quality of life-related concerns, is extremely important in the oncology setting. The integration of evidence-based complemenary medicine therapies within conventional palliative care can expand the available treatment options, especially for chemotherapy-induced toxicities for which conventional medicine options are often limited.
Editorial Integrating Complementary Medicine * *Corresponding author in Palliative Care: A Call for an Michael Silbermann, DMD, PhD Executive Director Middle East Cancer Consortium Inter-Disciplinary Collaboration 45 Yotam Street Haifa 34675, Israel E-mail: cancer@mecc-research.com 1,2 2,3 4* Eran Ben-Arye, MD ; Noah Samuels, MD ; Michael Silbermann, DMD, PhD Volume 2 : Issue 2 1 Integrative Oncology Program, The Oncology Service, Lin Medical Center, Clalit Health Article Ref. #: 1000PMHCOJ2e003 Services, Haifa and Western Galilee District, Haifa, Israel 2Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Article History 3Tal Center for Integrative Oncology, Institute of Oncology, Sheba Medical Center, Tel th Hashomer, Israel Received: September 20 , 2016 st 4 Accepted: September 21st, 2016 4Middle East Cancer Consortium, Haifa 34675, Israel nd Published: September 22nd, 2016 The interplay between complementary medicine and palliative care, both of which Citation emphasize a patient-centered approach in order to improve quality of life-related concerns, is Ben-Arye E, Samuels N, Silber- mann M. Integrating complemen- extremely important in the oncology setting. The integration of evidence-based complemen- tary medicine in palliative care: tary medicine therapies within conventional palliative care can expand the available treatment A call for an inter-disciplinary options, especially for chemotherapy-induced toxicities for which conventional medicine op- collaboration. Palliat Med Hosp tions are often limited. The integration of complementary medicine in palliative care may also Care Open J. 2016; 2(2): e7-e10.
doi: 10.17140/PMHCOJ-2-e003 provide an opportunity to address the bio-psycho-social-cultural-spiritual perspectives of care among those patients and caregivers for whom traditional medicine plays and important role in their health belief model. This integration should evolve as an inter-disciplinary process, as opposed to the intra-disciplinary approach which is being taken in most oncology settings. The inter-disciplinary approach recognizes the variance in approach to patient care, while facilitat- ing a multi-disciplinary approach and enabling specialists from both domains to provide care based on their clinical expertise as well as their perceived health-belief models of care.
Over the past four decades a paradigm shift has been occurring, in which patient-cen- tered care has become the focus of palliative medicine. Palliative care is taking place through- out the oncology setting, which recognizes the importance of addressing concerns related to the patient’s quality of life (QOL), and not only outcomes related to survival or other disease-cen- tered parameters. Palliative medicine provides therapeutic options which can reduce the level of suffering among patients and their caregivers, while addressing bio-physical, psychological, social and spiritual needs.1 Improving QOL may, in turn, lead to a reduction in the use of medi- cal services,2 and may even impact outcomes such as survival rates among patients undergoing treatment.3 In light of these findings, the American Society of Clinical Oncology guidelines recommend that “combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom bur- den”.4 The World Health Organization (WHO) has also addressed the importance of palliative care, and provides recommendations for the provision of these therapeutic options as part of standard care.5 Yet despite the widespread recognition of the importance of palliative care in the oncology setting, the WHO guidelines are often not being implemented, either because pallia- tive care therapies are not recommended as part of the treatment protocol or because they are Copyright not being integrated into standard medical practice.
©2016 Silbermann M. This is an open access article distributed un- der the Creative Commons Attribu- Complementary medicine (CM) includes a wide range of non-conventional therapies, tion 4.0 International License (CC such as traditional and systematic medical approaches; the use of herbal and non-herbal supple- BY 4.0), which permits unrestricted ments; and diverse methods of mind-body-spiritual, nutritional-based and manual-movement use, distribution, and reproduction therapies. CM use is widespread among patients with advanced cancer, with as many as 70% in any medium, provided the origi- nal work is properly cited. reporting this practice before, during and following active treatment.7 Many patients using CM believe that these therapies can prolong survival, enhance QOL, reduce chemotherapy-induced toxicities, and increase levels of 8-11 energy and function.8-11 For many patients with advanced cancer QOL is severely impaired, and the treatment options provided for this indication by conventional medicine is often limited in its effectiveness.12 As a result, many patients and their caregivers seek out “natural” remedies, frequently with the goal of curing their cancer, this despite the lack of any evidence as to their effectiveness and with a potential for adverse effects, including interactions with conventional oncology drugs.13 Integrative medicine is a concept of care which sees as its goal the integration of CM as part of standard conventional care. Integrative oncology seeks to supplement conventional supportive and palliative care, further enhancing patient QOL.14 Integra- tive oncology services have become part of an increasing number of leading cancer centers, and are typically headed by integrative physicians (IPs). The IP is an MD with dual training in complementary medicine and supportive care, working in a multidisciplinary team which includes CM practitioners who are either physicians, nurses or other health care practitioners, as well as non-medical practitioners of CM.15 Integrative oncology treatments are individualized and patient-tailored, while at the same time following the findings of evidence-based research regarding their effectiveness and safety. Much research has been conducted supporting both of these aspects of CM care, which include explanatory (randomized controlled trials) as well as pragmatic (non-controlled or observational) studies. This research has found a number of CM modalities to be effective and safe for a number of QOL-related concerns, such as the reduction of pain syndromes and improving mood with therapeutic massage16; reducing cancer-related fatigue, 17-19 chemotherapy-induced nausea and vomiting (CINV), anxiety and dyspnea with acupuncture ;and beneficial effects of herbal 20,21 products such as ginseng for CRF and ginger for CINV.
Integrative oncology emphasizes the importance and centrality of communication between the IP and the “circle of care” which includes the patients themselves and their caregivers, as well as the health care professionals responsible for their care (on- cologist, nurse-oncologist, psycho-oncologist, family physician and others). Maintaining open and non-judgmental communication between these parties is essential in establishing an effective and safe environment for the patient-tailored intervention. Such a plan needs to correspond with the concerns of patients and their caregivers, as well as addressing their expectations and willingness to undergo new and often unfamiliar treatment modalities. In addition to being tailored to individual needs and expectations, the inte- grative treatment plan needs to consider the social-cultural-religious context of the patient’s health belief model. This is especially true in regions such as the Middle East, where collective values often take precedence over those of the individual. Despite the difference in their fundamental conceptual paradigms, integrative oncology and palliative medicine share an approach which emphasizes the bio-psycho-spiritual and patient-centered aspects of patient care. Both recognize the importance of the need for continuity of care, which begins from the moment the cancer is diagnosed, through active treatment and finally ad- vanced cancer and end of life care. Both employ multi-disciplinary teams which include physicians, nurses, psycho-oncologists and other paramedical professionals in palliative care, and non-medical CM practitioners in integrative oncology. What, then, separates these two paradigms of care? How is the role of the IP different from that of the palliative care specialist? And finally, should the two domains exist separately in an inter-disciplinary framework, or should they co-exist within the same intra-disciplinary setting? Both palliative medicine and integrative oncology need to choose between specializing in one domain or maintaining a more broad and general perspective. The specialist approach tends to focus on the specifics, analyzing medical challenges from a top-to-bottom perspective which is atomistic and reductionist. In contrast, the generalist approach contemplates a more horizontal and inter-disciplinary view. Interestingly, many IPs and palliative care specialists come from specialties with a more generalist ori- entation, such as family and internal medicine, geriatrics and others. Indeed, IPs and palliative care specialists share a more periph- eral and holistic perspective when addressing QOL-related aspects of care. In addition to their conventional medical education, IPs chose to undergo additional CIM training which requires them to internalize medical philosophies which are not taught in medical schools and which often challenge conventional medicine concepts of care. Many IPs have also taken courses in CM treatments such as acupuncture, homeopathy, mind-body and other techniques, in order to better understand the tools available. As such, the IP should not be viewed merely as a CM practitioner with technical knowledge (e.g., acupuncture). Rather, IPs and their team of CM practitioners should be seen as providing a non-conventional understanding on the meaning of health vs. disease, as well as on the meaning of healing vs. medical management and treatment, especially for QOL-related concerns.
In order for an effective and true integrative process to take place, it is our belief that integrative oncology should take place in an inter-disciplinary model with palliative medicine care, and not one that is intra-disciplinary. We acknowledge the temptation to combine the two approaches. After all, an oncologist can become familiar with the use of herbal medicine; a psycho-oncologist can provide meditation and spiritual care; a palliative care specialist can insert acupuncture needles at designated points; and nurses can be trained in massage therapies such as reflexology. In practice, however, such a generalist approach is unlikely to succeed. The need for specialization in general fields of medicine is reflected in the establishment of subspecialty training in fields such as palliative medicine and psycho-oncology, and this should be the case for integrative medicine as well. Collaboration between IPs and palliative care specialists needs to be recognized for the many advantages which result from adopting an inter-disciplinary approach. This collaboration can be synergistic, with each discipline providing a solution for the other’s “blind spots”, significantly increasing the impact on QOL-related outcomes. The differences between these two para- digms of care are their strength, especially since both are committed to the same therapeutic goals. The IP consultation and CM treatments can supplement palliative care in cases where the conventional approach is not able to provide the necessary relief, as well as where there is an expectation regarding the patient’s health belief model. Collaboration between IPs and palliative medicine specialists may reduce the “burnout” which results from work with palliative care, inducing a process of post-traumatic growth. And finally, palliative care specialists and IPs need to see each other as essential to patient care, enriching each other and advancing an inter-disciplinary collaboration within their joint medical institution.