Impact of the 12-Gene Colon Cancer Assay on Clinical Decision Making for Adjuvant Therapy in Stage II Colon Cancer Patients.

OBJECTIVES: To evaluate the impact of the 12-gene Colon Cancer Recurrence Score Assay-a clinically validated prognosticator in stage II colon cancer after surgical resection-on adjuvant treatment decisions in T3 mismatch repair proficient (MMR-P) stage II colon cancer in clinical practice. METHODS: This retrospective analysis included all patients with T3 MMR-P stage II colon cancer (Clalit Health Services members) with Recurrence Score results (time frame January 2011 to May 2012). Treatment recommendations pretesting were compared with the treatments received. Changes were categorized as decreased (to observation alone/removing oxaliplatin from the therapy) or increased (from observation alone/adding oxaliplatin to the therapy) intensity. RESULTS: The analysis included 269 patients; 58%, 32%, and 10% of the values were in the low (<30), intermediate (30-40), and high (≥41) score groups, respectively. In 102 patients (38%), treatment changed post-testing (decreased/increased intensity 76/26 patients). The overall impact was decreased chemotherapy use (45.0% to 27.9%; P < 0.001). Treatment changes occurred in all score groups, but more frequently in the high (change rate 63.0%; 95% confidence interval [CI] 42.3%-80.6%) than in the intermediate (30.6%; 95% CI 21.0%-41.5%) and low (37.6%; 95% CI 30.0%-45.7%) score groups. The direction of the change was consistent with the assay result, with increased intensity more common in higher score values and decreased intensity more common in lower score values. CONCLUSIONS: Testing significantly affected adjuvant treatment in T3 MMR-P stage II colon cancer in clinical practice. The study is limited by its design, which compared treatment recommendations pretesting to actual treatments received post-testing, lack of a control group, and nonassessment of confounding factors that may have affected treatment decisions.

[Modeling integrative oncology care program for Arab patients in north Israel: towards quality of life improvement during chemotherapy].

BACKGROUND: In the last decade, a number of integrative oncology programs have been established within leading oncology departments in Israel aiming to provide consultations that address patients' concerns and improve their quality of life (QOL). OBJECTIVE: To identify Arab cancer patients' attitudes, needs and expectations concerning integration of complementary and traditional medicine (CTM) in their supportive oncology care. METHODS: This article presents studies based on both qualitative (including interviews with patients, oncologists and CTM practitioners) and quantitative studies which were designed to evaluate patients' attitudes, needs and expectations regarding CTM integration in supportive oncology care. RESULTS: Of the 313 Arab respondents, 109 reported on the use of herbal medicine for cancer-associated outcomes. Over 78% of respondents considered QOL improvement as their main expectation of integrated CM consultation. Similar expectations were expressed in studies exploring 155 cancer care practitioners in Israel and Arab countries, 27 CTM-trained Arab practitioners, and a sample of 15 Arab patients referred to integrative medicine consultation. CONCLUSIONS: Arab cancer patients support QOL-oriented integrated medicine programs provided in oncology settings. Integrative medicine consultation should provide patients with an evidence-based recommendation on efficacy and safety of herbs commonly used concomitant with chemotherapy. We recommend designing integrative oncology training courses for physicians who will provide evidence-based consultation attuned with Arab patients' needs, concerns and cultural-sensitive orientation.

Chemotherapy-related cognitive impairment: does integrating complementary medicine have something to add? Review of the literature.

Chemotherapy-related cognitive impairment is a phenomenon of cognitive decline that some patients experience during and after chemotherapy. The prevalence of chemotherapy-related cognitive impairment in cancer survivors ranges from 14 to 85 %. Memory loss and lack of concentration are the most frequent symptoms, often resulting in deterioration of daily functioning and a decreased quality of life. Despite ongoing research on chemotherapy-related cognitive impairment, a clear understanding of the underlying mechanisms of the neurotoxicity induced by chemotherapy and the factors that determine a patient's vulnerability are still lacking. We review current knowledge regarding the etiology of chemotherapy-related cognitive impairment, risk factors, conventional therapy, coping strategies, and potential complementary and integrative medicine treatments. Complementary and integrative medicine modalities that may improve chemotherapy-related cognitive impairment include mind-body techniques and acupuncture, as well as nutrition and herbal therapies. Studies on these modalities have not directly tested the hypothesis of modifying chemotherapy-related cognitive impairment and were done on different disorders of memory loss and lack of concentration. We recommend conducting further research on the potential role of complementary and integrative medicine modalities in the treatment and prevention of chemotherapy-related cognitive impairment.

Integrating complementary medicine and supportive care: patients' perspectives toward complementary medicine and spirituality.

OBJECTIVES: The association of spirituality and complementary and alternative medicine (CAM) in oncology is unfolding as a research theme that may have practical implications in supportive care. The purpose of this study was to explore patients' perspectives regarding CAM and spirituality in order to address their needs in an integrative oncology program. METHODS: A 27-item questionnaire was developed that was administered by research assistants to a convenience sample of patients attending a community-based oncology service in northern Israel. RESULTS: Of the 509 respondents, 302 (67.4%) were undergoing active oncological treatment and 146 (32.6%) were doing follow-up surveillance. Current and/or previous year CAM use for oncology treatment was reported by 244 of 495 respondents (49%). A logistic regression model indicated that CAM use was associated with younger age, Jewish religion, and higher cancer-related spiritual quest [EXP(B)=2.102, 95% confidence interval for EXP(B) 1.236-3.575, p=0.006]. Compared with patients with lower spiritual quest, CAM users with higher spiritual quest expressed more expectations of CAM counseling in the following themes: improving daily functioning and coping with disease, lessening chemotherapy side-effects, and supporting the patient and family emotionally and spiritually. In addition, they expected their social worker to be more involved in building the CAM treatment plan compared to patients with average spiritual quest (35.3% versus 16.3%, p=0.038). CONCLUSIONS: Higher degree of spiritual quest is associated with increased CAM use, and higher expectations from CAM providers and social workers in the context of CAM integration within cancer care.

Modeling an integrative oncology program within a community-centered oncology service in Israel.

OBJECTIVE: Describing the processes that preceded the opening of an integrative oncology program (IOP) within the oncology service (OS) of the largest health maintenance organization in northern Israel. METHODS: The groundwork towards initiation of the IOP was based on three key elements (1) Interviews with patients, practitioners and directors were performed in order to explore perspectives regarding complementary medicine integration (CM) within the OS; (2) review of research data on CM efficacy and safety in cancer care; (3) critical comparative analysis of seven models of IOPs in Israel, Europe, and the U.S. RESULTS: Ninety-three interviews included 24 patients, 34 conventional practitioners, 9 medical directors, and 26 CM-trained practitioners. The interviews revealed that there is a need for CM in the OS, aimed towards improving patients' well-being during chemotherapy and advanced disease. An integrative oncology score (IOS) was formulated based on 6 themes considered promoters of successful integration. CONCLUSIONS: Integration of CM within an oncology service should address patients' needs and research knowledge and be built upon mandatory practitioners' communication. PRACTICE IMPLICATIONS: IOP modeling necessitates in-depth study aimed at revealing the OS needs and expectations, adjusting research data to the OS clinical challenges, and tailoring an appropriate model of integrative care.

Barriers to integration of traditional and complementary medicine in supportive cancer care of arab patients in northern Israel.

In 2008, an Integrative Oncology Program (IOP), aiming to improve patients' quality of life during chemotherapy and advanced cancer, was launched within the Clalit Health Organization's oncology service at the Lin Medical Center, Haifa, Israel. The IOP clinical activity is documented using a research-based registry protocol. In this study, we present an analysis of the registry protocol of 15 Arab patients with cancer who were referred to the IOP. Analysis of patients' reported outcomes using the Edmonton Symptom Assessment Scale suggests that integrative medicine care improves fatigue (P = 0.024), nausea (P = 0.043), depression (P = 0.012), anxiety (P = 0.044), appetite (P = 0.012), and general well-being (P = 0.031). Barriers to integration of traditional and complementary medicine in supportive care of Arab patients are discussed followed by six practical recommendations aimed at improving accessibility of patients to integrative supportive care, as well as compliance with treatments.

Attitudes of patients with gynecological and breast cancer toward integration of complementary medicine in cancer care.

OBJECTIVE: The purpose of this study was to explore prospectively the perspectives of patients with breast and gynecological cancers regarding integration of complementary and alternative medicine (CAM) in conventional oncology settings. METHODS: We developed a 27-item questionnaire that was administered to convenient sample of patients with breast cancer and another with gynecological cancer who were attending a community-based oncology service in northern Israel. RESULTS: Of the 275 respondents, 109 (39.6%) had gynecological cancers and 166 (60.4%) had breast cancer. Current and/or previous year CAM use for oncology treatment was significantly higher among the patients with gynecological cancer (73/166 [44%] vs 67/106 [63%], P = 0.03). A logistic regression model indicated that CAM use was associated with gynecological cancer (EXP [B], 2.51; 95% confidence interval for EXP [B], 1.29-4.88; P = 0.007], younger age, Jewish religion, and lesser degree of religiosity. The patients highly expected their gynecologist-oncologist and family doctor to refer them to CAM counseling. Moreover, they expected their gynecologist-oncologist to participate in building a CAM treatment plan if CAM were to be integrated into the oncology service. The patients expected the CAM consultant to inform them of the safety and efficacy of CAM treatments, emphasizing expectations to strengthen their general ability to cope with the disease, reduce chemotherapy side effects, and provide emotional and spiritual support. CONCLUSION: Although patients with gynecological malignancies use CAM significantly more than patients with breast cancer, both groups share similar conceptions regarding the active role of their gynecologist oncologists in the process of CAM integration within supportive care and expect CAM consultation to focus on improving their well-being.

[Integrating complementary medicine in oncology supportive care: assessment of patients' needs and expectations during chemotherapy].

BACKGROUND: During the Last decade complementary medicine is gradually being integrated within conventional oncology care in Western countries. In 2008, an integrative oncology program was implemented within the Clalit Oncology Service (COS) of the Haifa and Western-Galilee district of Clalit Health Organization aiming to promote patients' well-being during chemotherapy and in advanced disease. OBJECTIVE: To identify needs and distress of patients with regard to combining complementary medicine with the supporting treatment for improvement of quality of life. METHODS: A study using semi-constructed interviews with 31 patients during chemotherapy was performed at two outpatient oncology centers of the Clalit HMO in northern Israel. RESULTS: Most participants reported significant deterioration in their quality of life during chemotherapy, mainly related to fatigue, work cessation and mood disorder. Interest in complementary medicine significantly correlated with the participants' awareness of the mind-body connection. Most participants reported on their interest to consult with physicians specializing in complementary medicine as an integral part of the oncology service care. The most favorable complementary therapies reported by patients were nutritional counseling, herbal medicine and traditional healing. CONCLUSIONS: Asking patients during chemotherapy on their beliefs regarding mind and body connections may be used as a screening question to identify patients interested in experiencing complementary therapies. Integrating physician counseling regarding complementary medicine within the oncology service may address patients' needs and concerns by matching therapies to specific symptoms and chemotherapy side-effects.

Wheatgrass in Afifi's garden: sprouting integrative oncology collaborations in the Middle East.

We suggest that bridging traditional and modern medicine can in many cases empower patients and enable them to better cope with cancer treatment. Our experiences in the Middle East might be applicable to other areas of the world facing a similar need to integrate evidence-based medicine with narrative-based, ethics-based, and ethnic medicine in the practice of oncology. In addition,we hope that our common efforts will encourage future collaboration among scientists and clinicians in the Middle East, which in turn might promote understanding, tolerance, and mutual respect among professionals in an area of the world troubled by ongoing geopolitical conflict.