VOLUME 29 ⅐ NUMBER 7 ⅐ MARCH 1 2011 JOURNAL OF CLINICAL ONCOLOGY THE ART OF ONCOLOGY Wheatgrass in Afifi’s Garden: Sprouting Integrative Oncology Collaborations in the Middle East Eran Ben-Arye, Elad Schiff, Mariana Steiner, and Michael Silbermann From the Lin Medical Center, Clalit Afifi’s Story of an interrelated process—a curse involving the Health Services; Technion-Israel Insti- Afifi, a 46-year-old mother of four children, was stomach of Afifi and the spleen of Saleh. tute of Technology; Bnai-Zion Hospital; International Center for Health, Law admitted to the oncology service at the Lin Medical The IP asked Afifi about her main expectations and Ethics, Haifa University; and Middle Center in Haifa, Israel, after partial gastrectomy and regarding the integrative consultation. Afifi was in- East Cancer Consortium, Haifa, Israel. omentectomy for locally advanced stomach carci- terested in symptom control, with fatigue and pain Submitted October 26, 2010; accepted noma. After the first adjuvant chemotherapy treat- being the most bothersome. She also wanted to December 6, 2010; published online ahead of print at www.jco.org on ment with cisplatin, epirubicin, and fluorouracil know more about what to eat or avoid eating during January 10, 2011. (CEF), Afifi suffered extreme fatigue, dizziness and the chemotherapy treatment. Although Afifi had Authors’ disclosures of potential con- lightheadedness, headaches, shoulder pain, mouth had a consultation with a clinical dietician after sur- flicts of interest and author contribu- sores, nausea and vomiting, severe diarrhea, poor gery, she still sought physician guidance about in- tions are found at the end of this appetite, difficulty sleeping, and bothersome anx- gesting foods and plants, because she had already article. iety. Afifi’s medical oncologist referred her for a lost 9 kg. The severity of symptoms, concerns, and Corresponding author: Eran Ben-Arye, consultation with an integrative physician (IP) prac- expectations were evaluated by the IP using the MD, Integrative Oncology Program, The Oncology Service, Lin Medical Center, ticing complementary medicine, with the aim of Edmonton Symptom Assessment Scale (ESAS) 35 Rothschild St, Haifa, Israel 35152; having her distressing symptoms addressed. The IP and Measure Yourself Concerns and Wellbeing e-mail: [email protected]. to whom Afifi was referred was a family medicine (MYCAW) questionnaires as well as a detailed bio- © 2011 by American Society of Clinical specialist, skilled in supportive care–oriented com- psycho-spiritual assessment. Oncology plementary and traditional medicine, who directs an Although Afifi stated that she had not used any 0732-183X/11/2907-944/$20.00 integrative oncology program within the Lin Medi- alternative, traditional, or complementary treat- DOI: 10.1200/JCO.2010.33.4532 cal Center oncology service. ments for her cancer, nor had she used any in the The initial integrative medicine consultation past for other medical conditions, the IP learned that was scheduled before the start of Afifi’s second she was interested in medicinal herbs commonly chemotherapy cycle. Afifi entered the consultation used in traditional Druze cuisine. Accordingly, the room accompanied by her husband, Saleh, and her physician suggested incorporating several herbs ref- sister. Afifi and her sister wore the traditional dress erenced in traditional Islamic texts on medicine for of the Druze community, a unique monotheistic the treatment of Afifi’s troublesome symptoms: religious and cultural group found in Israel and carob extract (Ceratonia siliqua) mixed with minced neighboring countries. The conversation took place fresh sage leaves (Salvia fruticosa Miller) for the in Hebrew and Arabic (the Druze use the Arabic treatment of mouth sores, tea prepared from pome- language), starting with Saleh’s description of his granate extract (Punica granatum) mixed with bay wife as a housewife caring full time for the well-being leaves (Laurus nobilis) to alleviate stomach pain and of the family. They lived in a small Druze village diarrhea, fresh ginger (Zingiber officinale) mixed located in the Galilee, in northern Israel, 50 kilome- with fresh green salad for the first 3 days after chem- ters from the oncology medical center. otherapy to lessen nausea, and other herbal reme- After Saleh had finished speaking, the IP asked dies. The integrative oncology assessment and Afifi how she perceived her disease. Afifi noted that treatment plan were documented in Afifi’s medical the first symptoms of her illness, upper abdominal record along with evidence-based data regarding the pains, were similar to what her husband had experi- efficacy and safety of the herbs and their potential enced 8 months earlier; he was ultimately diagnosed interactions with Afifi’s current chemotherapy regi- with splenic lymphoma. One day, while Afifi was men. The IP referred brief reports to Afifi’s caregiv- busy fulfilling traditional familial obligations, she ers within the multiprofessional team. felt severe and searing abdominal pain. This resulted Nine days later, during the second week of the in admission to the hospital, where she was ulti- second adjuvant chemotherapy cycle, Afifi stated mately diagnosed with gastric cancer. Both Afifi and that her mouth sores had significantly improved. Saleh perceived the cancers afflicting them as parts She presented fresh leaves her family had collected in 944 © 2011 by American Society of Clinical Oncology Downloaded from jco.ascopubs.org on February 25, 2011. For personal use only. No other uses without permission. Copyright © 2011 American Society of Clinical Oncology. All rights reserved. The Art of Oncology the mountains surrounding their village. After discussing the potential Afifi’s coexisting health-belief models. The first was inwardly and efficacy and safety of these herbs, the IP suggested also undergoing traditionally oriented and was complemented by the other belief acupuncture treatment to ameliorate fatigue and nausea. Afifi agreed through the powerful external interventions of modern oncology. to the acupuncture, with the understanding that the points selected Both were necessary in her journey of healing. would be located on the distal hands and feet to maintain her cultural Smithson et al1 in the United Kingdom performed a systematic and religious value of modesty. literature search and meta-ethnography (ie, synthesis of qualitative The third appointment with the IP was scheduled 1 day after the and interpretive ethnographic research) to synthesize key concepts in third cycle of chemotherapy. Although Afifi felt significant fatigue, she the experiences of patients with cancer using complementary and expressed optimism because she gained 2 kg of weight. Afifi reported alternative medicine (CAM) and concluded that integrated advice and daily use of freshly squeezed wheatgrass juice, which had been highly services are highly valued by patients. During the last decade, Journal of recommended by a traditional practitioner living in a nearby Druze Clinical Oncology and other journals have published notable studies village. She was surprised by but at the same time seemed pleased on the prevalence of CAM use among patients with cancer,2-5 perspec- with the IP’s suggestion to continue to collaborate with this tradi- tives of CAM users,6 the low disclosure of CAM use to oncologists,7 tional practitioner. and implications of CAM use for research and clinical care.8 Increased Over the next five IP visits, Afifi was treated with acupuncture research on efficacy and the lack thereof 9,10 and on safety and combined with breathing exercises and guided imagery. Dietary and risks11 of complementary therapies has marked the need for special- herbal recommendations were changed and adapted to Afifi’s symp- ized integrative CAM programs to be implemented in leading oncol- toms and chemotherapy schedule. Afifi made enormous efforts to ogy care institutions in the United States, supported by governmental come to the oncology medical center despite a long drive. Three days agencies such as the Office of Cancer Complementary and Alternative after Afifi’s final chemotherapy treatment, a concluding assessment Medicine at the National Cancer Institute.12 compared ESAS and MYCAW questionnaire results with pretreat- The term integrative oncology was coined to emphasize the dia- ment measurements. Significant improvements were reported re- logue between CAM providers, oncologists, family practitioners, and garding Afifi’s previous concerns of diet and fatigue and her other health care providers who envision an extended and holistic evaluation of pain, fatigue, nausea, depression, anxiety, sleep, appetite, patient-centered approach in oncology care. Integrative oncology ser- and general well-being. At the bottom of the MYCAW questionnaire, vices focus mainly on supportive and palliative care and are challenged Afifi was asked to describe the effects of the treatment in her own daily by the need to model a patient-tailored treatment program that words. She wrote, “Following the needle treatment [acupuncture], I will comply with a patient’s expectations, concerns, needs, and symp- felt better in my tiredness, appetite, nausea and sleep; the herbs assisted toms, along with assurance of its efficacy, safety, lack of interactions in treating the mouth sores and my sense of taste is significantly better. with chemotherapy treatment, and cost considerations. In the case Herbs also helped in treating diarrhea, and I feel stronger.” A few days described here, Afifi challenged both the IP and her oncologist with later,