A randomized, controlled clinical trial of the homeopathic medication TRAUMEEL S in the treatment of chemotherapy-induced stomatitis in children undergoing stem cell transplantation

Integrative Medicine Across the Pediatric Cancer Care Trajectory: A Narrative Review

PURPOSE OF THE REVIEW

Children and adolescents with cancer, along with their parents and other informal caregivers, often report using complementary and alternative medicine (CAM) during active oncology and hemato-oncology treatment. Some adopt an "alternative" approach to conventional medical care, which often entails the use of these practices without the knowledge of the treating pediatrician. In contrast, many others search for consultation provided by a pediatric integrative oncology (IO) practitioner working with the conventional medical team. IO seeks to provide evidence-based complementary medicine therapies, many of which have been shown to augment conventional supportive and palliative care, while ensuring the patient's safety. The present narrative review examines the current state of and future direction for the IO setting of care.

RECENT FINDINGS

A large body of published clinical research supports the effectiveness of leading Pediatric IO modalities, while addressing potential safety-related concerns. Despite the growing amount of clinical research supporting the beneficial effects and implementation of Pediatric IO models of care, there is still a need for further studies in order to establish clinical guidelines in the treatment of children and adolescents with cancer. Such IO-directed guidelines will need to address both the effectiveness and the safety of the CAM modalities being used in pediatric oncology and hemato-oncology settings, promoting a better understanding among pediatric healthcare professionals and helping them understand the indications for referral to the IO treatment service.

Integrative Approaches for Cancer Pain Management

PURPOSE OF REVIEW

The goal of this review is to summarize updates to the broad array of complementary therapies available for cancer pain. This paper will serve as a reference for clinicians managing pain in cancer patients.

RECENT FINDINGS

Patients are embracing integrative therapies in growing numbers; clinicians must be prepared to incorporate these therapies into patients' existing treatment regimens. This requires knowledge regarding risks, benefits, and potential interactions with existing cancer therapies. Integrative cancer pain management strategies have shown promise, with several proven effective for the management of cancer pain. Energy therapies, including acupuncture, and biologicals and nutraceuticals including overall diet and vitamin D, have the highest level of evidence for efficacy. The remaining therapies discussed in this chapter may be beneficial for patients on a case-by-case basis; risks and benefits of each individual therapy as described in the text must be further assessed in future rigorous trials to further clarify the role of these complementary therapies in cancer pain management.

The Anti-Inflammatory Activity of Viscum album

The therapeutic story of European mistletoe (Viscum album L.) presents a seesawing profile. In ancient times, this hemiparasitic plant was considered a panacea and even to be endowed with exceptional beneficial properties. In more recent times, despite its multiple uses in traditional medicines, some parts of the plant, in particular the berries, were considered poisonous and dangerous, including concerns of cytotoxicity, which spread serious suspicion on its medicinal utility. However, since the last century, medical interest in mistletoe has come back in force due to its utilization in clinical cancer treatments, based on its selective action on tumor cells. In Central Europe, the hydro-alcoholic extracts of European mistletoe register a relevant and continuous utilization in anthroposophic medicine, which is a holistic system that includes the utilization of phytomedicinal substances. In Switzerland and Germany, most physicians and patients use these products as complementary therapy in oncological treatments. However, despite its increasing use in this field, the results of mistletoe's use are not always convincing, and other aspects have appeared. Nowadays, products that contain mistletoe are utilized in several fields, including diet, phytotherapy, veterinary medicine and homeopathy, but in particular in cancer therapies as coadjuvant factors, in consideration of several positive effects including effects in the improvement of quality-of-life conditions and reinforcement of the immune system. In this review, based on the understanding of the association between cancer and inflammation, we propose a relationship between these recent uses of mistletoe, based on its antioxidant properties, which are supported by phytochemical and pharmacological data. The unicity of mistletoe metabolism, which is a direct consequence of its hemiparasitism, is utilized as a key interpretation element to explain its biological properties and steer its consequent therapeutic uses.

Benefits of Homeopathic Complementary Treatment in Patients With Breast Cancer: A Retrospective Cohort Study Based on the French Nationwide Healthcare Database

BACKGROUND

Complementary therapy in oncology aims to help patients better cope with the illness and side effects (SEs) of cancer treatments that affect their quality of life (QOL). This study aimed to assess the benefits of homeopathic treatment on the health-related QOL (HRQOL) of patients with non-metastatic breast cancer (BC) prescribed in postsurgical complementary therapy.

PATIENTS AND METHODS

An extraction from the French nationwide healthcare database targeted all patients who underwent mastectomy for newly diagnosed BC between 2012 and 2013. HRQOL was proxied by the quantity of medication used to palliate the SEs of cancer treatments.

RESULTS

A total of 98,009 patients were included (mean age: 61 ± 13 years). Homeopathy was used in 11%, 26%, and 22% of patients respectively during the 7 to 12 months before surgery, the 6 months before, and 6 months after. Thereafter, the use remained stable at 15% for 4 years. Six months after surgery, there was a significant overall decrease (RR = 0.88, confidence interval (CI)₉₅ = 0.87-0.89) in the dispensing of medication associated with SEs in patients treated with ≥ 3 dispensing of homeopathy compared to none. The decrease appeared to be greater for immunostimulants (RR = 0.79, (CI)₉₅ = 0.74-0.84), corticosteroids (RR = 0.82, (CI)₉₅ = 0.79-0.85), and antidiarrheals (RR = 0.83, (CI)₉₅ = 0.77-0.88).

CONCLUSION

The study showed an increasing use of homeopathy in patients with BC following diagnosis. This use was maintained after surgery and seemed to play a role in helping patients to better tolerate the SEs of cancer treatments.

[Alternative medicine in uro-oncology]

BACKGROUND

Alternative medicine is used instead of conventional therapy. Some patients use it in parallel with conventional medicine.

OBJECTIVE

Narrative compilation of the evidence on alternative medicine in the (uro)oncological context.

MATERIALS AND METHODS

A selective literature search in MEDLINE via PubMed was performed.

RESULTS

The data on 3‑bromopyruvate, Miracle Mineral Supplement (MMS), insulin-potentiated therapy, base therapy, hyperthermia, Artemisia annua, amygdalin (vitamin B17), Amanita therapy, homeopathy, apitherapy, dendritic cells, galavit, Germanic new medicine, and spiritual healing show either no or little clinical evidence of efficacy or clearly exhibit a negative benefit-risk profile.

CONCLUSIONS

Alternative medicine is pseudo-medicine that may have a positive effect on mental well-being in the short term, but is mostly associated with disadvantages for the patient in the long term.

Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline

PURPOSE

The aim of this joint guideline is to provide evidence-based recommendations to practicing physicians and other health care providers on integrative approaches to managing pain in patients with cancer.

METHODS

The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, and patient advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included pain intensity, symptom relief, and adverse events. Expert panel members used this evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 227 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Among adult patients, acupuncture should be recommended for aromatase inhibitor-related joint pain. Acupuncture or reflexology or acupressure may be recommended for general cancer pain or musculoskeletal pain. Hypnosis may be recommended to patients who experience procedural pain. Massage may be recommended to patients experiencing pain during palliative or hospice care. These recommendations are based on an intermediate level of evidence, benefit outweighing risk, and with moderate strength of recommendation. The quality of evidence for other mind-body interventions or natural products for pain is either low or inconclusive. There is insufficient or inconclusive evidence to make recommendations for pediatric patients. More research is needed to better characterize the role of integrative medicine interventions in the care of patients with cancer.Additional information is available at https://integrativeonc.org/practice-guidelines/guidelines and www.asco.org/survivorship-guidelines.

Effect of Ointments of Sulphur or Pyrogenium on Larvae of Cochliomyia hominivorax (Diptera: Calliphoridae)

BACKGROUND

 Myiasis by Cochliomyia hominivorax (Diptera: Calliphoridae) is a serious problem in animal health in tropical and sub-tropical regions. Ointment-type preparations are a good option of formulation in cases of myiasis in farm and pet animals. Sulphur and Pyrogenium have already shown in-vitro efficacy on C. hominivorax. This article describes an in-vitro experiment to test the inhibition of development from exposing larvae of C. hominivorax to two homeopathic ointments (prepared individually with Sulphur or Pyrogenium).

METHODS

 The homeopathic ointments were produced by mixing sterile lanolin, tocopherol and homeopathic medicine on a hydroalcoholic basis according to the Brazilian Homeopathic Pharmacopoeia. Larvae were obtained from naturally occurring myiases in sheep (wild larvae) or from a laboratory colony. The test consisted of exposing a group of 10 third-stage C. hominivorax wild larvae in contact with Sulphur or Pyrogenium ointment, or a group of 15 laboratory-propagated larvae in contact with the alcoholic vehicle of the ointment or homeopathic medicines prepared in sterile water (Sulphur or Pyrogenium), and observing the effect on the development, longevity and fertility of the blow-fly specimens.

RESULTS

 The C. hominivorax larval inhibition rate was 90.0% for the Sulphur ointment group and was 86.0% for the Pyrogenium ointment group. The non-alcoholic vehicle and the alcoholic vehicle inhibited the development of 24.0% and 22.08% of the larvae respectively. Sulphur prepared in sterile water inhibited the development of 74.67% and Pyrogenium in sterile water inhibited 73.33% of larvae. Specimens that survived contact with homeopathic ointments had their longevity decreased and did not reproduce.

CONCLUSION

 Ointments of Sulphur or Pyrogenium were able to inhibit the development of C. hominivorax larvae. The ointment vehicle was harmless.

Counseling on Complementary Methods in the Treatment of Side Effects of Oncological Therapies: A Project of the Breast and Bowel Center Nahe at the Hospital Sankt Marienwoerth Bad Kreuznach

BACKGROUND

Increasingly, patients with cancer are asking for additional, complementary therapy options for treating the side effects of oncological therapy. Thus, the members of the Breast and Bowel Center Nahe at the Sankt Marienwörth Hospital Bad Kreuznach decided to define the content of this type of counseling for patients before treatment.

METHODS

In 2018, a team of internal oncologists, gynecological oncologists, radio-oncologists, nutritionists, psycho-oncologists, and study nurses met several times to define the content of counseling. To inform the team, an intensive literature review was conducted.

RESULTS

Counseling content was determined for complementary treatment options for the most frequent side effects of oncological therapies. Counseling sessions were formulated as frontal lectures (slide presentations), given at regular intervals for patients and relatives. These lectures were highly appreciated by patients.

CONCLUSION

These counseling sessions increased patient understanding of both useful complementary measures and harmful measures they should not use.

Systematic Review on the Use of Homeopathy in Dentistry: Critical Analysis of Clinical Trials

Objectives: The objective of this research was to systematically map the literature on homeopathy and dentistry studies and to evaluate the effectiveness of using homeopathy in dental practice through the critical analysis of clinical studies. Design: The search for scientific articles in any language, year, and place of publication was made in the databases of Public Medline (PUBMED), Web of Science, Cochrane, and Virtual Health Library; the articles selected were later classified according to the type of study. Gray literature was accessed through Google Scholar. Clinical trials were analyzed for methodological quality. Two previously trained reviewers accomplished the entire process independently. Results: Of the 281 studies retrieved by means of the search, 44 met the eligibility criteria, with prevalence of literature reviews (56.8%), followed by clinical trials (34.1%), cross-sectional studies (6.8%), laboratory research (6.8%), and longitudinal observational studies (4.5%). The clinical trials identified were published from 1965 to 2019, using homeopathy in several dental specialties: in Endodontics, Periodontics, Orofacial Pain, Surgery, Pediatric Dentistry, and Stomatology, as well as in cases of dental anxiety. Qualitative failures, in all criteria investigated, and positive influences of the individual prescriptions on the results of treatments reported were observed. Conclusions: There is still a scarcity of studies about homeopathy and dentistry. The clinical trials selected showed positive effects on oral health; however, when they were critically evaluated, it was possible to recognize qualitative failures, mainly relative to double-blinding. It is necessary to encourage research on the subject, using standardized methodological procedures, to obtain better evaluation of the clinical applicability.

MASCC/ISOO clinical practice guidelines for the management of mucositis: sub-analysis of current interventions for the management of oral mucositis in pediatric cancer patients

OBJECTIVE

The aim of this sub-analysis was to highlight the MASCC/ISOO clinical practice guidelines for the management of oral mucositis (OM) in pediatric patients and to present unique considerations in this patient population.

METHODS

This sub-analysis of the pediatric patient population is based on the systematic review conducted by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISSO) published in 2019/2020. Studies were scored and assigned a level of evidence based on previously published criteria. Data regarding adverse effects and compliance was collected from the original publications.

RESULTS

A total of 45 papers were included and assessed in this sub-analysis, including 21 randomized controlled trials (RCTs). Chewing gum was demonstrated to be not effective in preventing OM in pediatric cancer patients in 2 RCTs. The efficacy of all other interventions could not be determined based on the available literature.

CONCLUSION

There is limited or conflicting evidence about interventions for the management of OM in pediatric cancer patients, except for chewing gum which was ineffective for prevention. Therefore, currently, data from adult studies may need to be extrapolated for the management of pediatric patients. Honey and photobiomodulation therapy in this patient population had encouraging potential. Implementation of a basic oral care protocol is advised amid lack of high level of evidence studies.

Oral mucositis: the hidden side of cancer therapy

Inflammation response of epithelial mucosa to chemo- radiotherapy cytotoxic effects leads to mucositis, a painful side effect of antineoplastic treatments. About 40% of the patients treated with chemotherapy develop mucositis; this percentage rises to about 90% for head and neck cancer patients (HNC) treated with both chemo- and radiotherapy. 19% of the latter will be hospitalized and will experience a delay in antineoplastic treatment for high-grade mucositis management, resulting in a reduction of the quality of life, a worse prognosis and an increase in patient management costs. Currently, several interventions and prevention guidelines are available, but their effectiveness is uncertain. This review comprehensively describes mucositis, debating the impact of standard chemo-radiotherapy and targeted therapy on mucositis development and pointing out the limits and the benefits of current mucositis treatment strategies and assessment guidelines. Moreover, the review critically examines the feasibility of the existing biomarkers to predict patient risk of developing oral mucositis and their role in early diagnosis. Despite the expression levels of some proteins involved in the inflammation response, such as TNF-α or IL-1β, partially correlate with mucositis process, their presence does not exclude others mucositis-independent inflammation events. This strongly suggests the need to discover biomarkers that specifically feature mucositis process development. Non-coding RNAs might hold this potential.

Material Risks of Homeopathic Medicinal Products: Regulatory Frameworks, Results of Preclinical Toxicology, and Clinical Meta-Analyses and Their Implications

Homeopathy is widely used and broadly accepted by health care professionals and the general public but less in academic circles. To assess possible material health risks of homeopathic medicinal products, it is necessary to identify, select, and synthesize the findings of recent reviews of controlled homeopathic clinical trials. Matching these findings with experimental data from toxicological studies helps to clarify what is known and not known about the material risks of homeopathic medicines. Rules for toxicological risk assessment and management need to be applied independently of individual attitudes towards specific therapeutic options. European regulatory bodies have developed special protocols and decision trees to assure the safety of nonindividualized homeopathic remedies. This narrative review leads to suggestions that could ease and improve toxicological decision making. No homeopathy-specific type or pattern of side effects could be extracted from the meta-analysis data. No differences in the frequency of adverse reactions between homeopathic treatment and placebo treatment could be seen, no matter whether adverse events were reported in a quantitative or a qualitative manner. Some patterns of side effects show that adverse reactions do not necessarily correlate with treatment but with the condition of the patient. Overall, the controlled clinical data available for the material risk assessment of homeopathic remedies support the statement that, if a risk exists, it must be so small that it has not yet been established. To make our risk findings useful for personal decisions regarding homeopathy, we provide a thought experiment based on four different health situations and ask the question: is homeopathy as a monotherapy or as an add-on treatment an option or should it be rejected?

Systematic review of natural and miscellaneous agents, for the management of oral mucositis in cancer patients and clinical practice guidelines - part 2: honey, herbal compounds, saliva stimulants, probiotics, and miscellaneous agents

OBJECTIVE

To update the clinical practice guidelines for the management of oral mucositis (OM) that were developed by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). This part focuses on honey, herbal compounds, saliva stimulants, probiotics, and miscellaneous agents.

METHODS

A systematic review was conducted by the Mucositis Study Group of MASCC/ISOO. The body of evidence for each intervention, in each clinical setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, one of the following guidelines were determined: Recommendation, Suggestion, No Guideline Possible.

RESULTS

A total of 78 papers were identified within the scope of this section, of which 49 were included in this review and merged with nine publications that were reported in the previous guidelines update. A new Suggestion was made for honey (combined topical and systemic delivery) for the prevention of OM in head and neck cancer patients receiving radiotherapy with or without chemotherapy. A new Suggestion clarified that chewing gum is not effective for the prevention of OM in pediatric patients with hematological or solid cancer treated with chemotherapy. No guideline was possible for other interventions.

CONCLUSIONS

Numerous natural products and herbal remedies were studied for the management of OM. Of the agents reviewed in this systematic review, a guideline in favor was made for honey (combined topical and systemic), while a guideline against was made for chewing gum. Additional research is warranted to clarify the potential of other interventions.

[Bioregulatory drugs in the prevention of complications in the early postoperative period in patients after septoplasty and FESS]

OBJECTIVE

To evaluate the effectiveness of the use of bioregulatory drugs for the prevention of complications in the early postoperative period in patients after septoplasty and FESS.

PATIENTS AND METHODS

We performed surgical treatment of 25 patients with chronic rhinosinusitis with frequent exacerbations without polyps. The extent of operation was septoplasty and FESS (polysinusotomy). In the postoperative period after septoplasty and functional endoscopic surgery on the paranasal sinuses (PNSs), along with systemic antibiotic therapy, irrigation therapy and nasal cavity cleaning under the endoscope control, Traumeel S in tablets was used 1 tablet 3 times a day 15 minutes before meals for 10 days. In the nasal cavity, after washing with a normalized solution of sea salt, Euphorbium Compositum Nazentropfen S, 1-2 spray 3 times a day for 10 days, was used as monotherapy. The control group included 25 patients with chronic rhinosinusitis with frequent exacerbations without polyps, comparable in age, sex, duration of the disease and the extent of surgery with the main group.

RESULTS

Accelerating the processes of wound healing, re-epithelialization, reducing reactive changes in the mucous membranes of PNSs, reducing postoperative edema with the use of naturally occurring drugs Euphorbium Compositum Nazentropfen S and Traumeel S helps minimize pathological effects on the epithelium of PNSs and the nasal cavity, accelerates the regeneration time of the ciliary epithelium and improves mucus function.

CONCLUSION

The bioregulatory drugs Euphorbium Compositum with Nazentropfen S and Traumeel S can be effectively used in the treatment of patients after rhinosurgical interventions in order to accelerate reparative processes and restore the function of the ciliated epithelium, do not cause addiction and "withdrawal syndrome" and do not have an irritating effect on the nasal mucosa and PNSs.

In vitro attenuation of classic metastatic melanoma‑related features by highly diluted natural complexes: Molecular and functional analyses

Metastasis is responsible for the majority of deaths among patients with malignant melanoma. Despite recent advances, the majority of current and modern therapies are ineffective and/or financially unfeasible. Thus, in this study, we investigated two low‑cost highly‑diluted natural complexes (HDNCs) that have been shown to be effective against malignant melanoma in a murine model in vivo. The aim of this study was to determine the mechanisms through which these HDNCs directly affect melanoma cells, either alone or in an artificial tumor microenvironment, suppressing the metastatic phenotype, thus explaining previous in vivo effects. For this purpose, HDNC in vitro treatments of B16‑F10 melanoma cells, alone or in co‑culture with Balb/3T3 fibroblasts, were carried out. Molecular biology techniques and standard functional assays were used to assess the changes in molecule expression and in cell behaviors related to the metastatic phenotype. Melanoma progression features were found to be regulated by HDNCs. Molecules related to cell adhesion (N‑cadherin, β1‑integrin and CD44), and migration, extracellular matrix remodeling and angiogenesis were modulated. The cell migratory, invasive and clonogenic capacities were reduced by the HDNCs. No loss of cell proliferation or viability were observed. On the whole, the findings of this study indicate that HDNCs directly reprogram, molecularly and functionally, melanoma cells in vitro, modulating their metastatic phenotype. Such findings are likely to be responsible for the attenuation of tumor growth and lung colonization previously observed in vivo.

Comparative evaluation of analgesic and anti-inflammatory efficacy of ibuprofen and traumeel after periodontal flap surgery: A randomized triple-blind clinical trial

Background:

Pain management after performing flap surgery is of paramount importance. Taking into consideration the side effects of nonsteroidal anti-inflammatory drugs (NSAIDs), and the advantages of homeopathic medication, the analgesic and anti-inflammatory properties of ibuprofen (NSAID) and traumeel (homeopathic AID) following flap surgery were evaluated.

Materials and Methods:

A randomized, triple-blinded, split-mouth clinical trial, with a sample size of 20 (age range of 20–60 years) was planned. Subjects included patients diagnosed with moderate chronic generalized periodontitis. Two quadrants for each subject were operated on, with an interval of 3 weeks. Random assignment of the operated quadrants to the following medication protocols was carried out by a third person: Ibuprofen, 600 mg and traumeel, 600 mg (up to three tablets) every 8 h for first 24 h and SOS (Si Opus Sit/if needed) thereafter for a period of 1 week as pain medication, respectively. After 1 week, sutures were removed. Primary outcomes were mean postoperative pain (modified visual analog scale) and number of tablets consumed in 1 week. The secondary outcome was postoperative tissue response. Any adverse effects were recorded.

Results:

Number of tablets consumed and pain perception was lower in traumeel compared to ibuprofen Group (P < 0.001). A better tissue response was shown by the group treated with traumeel as compared to the ibuprofen receiving group (P < 0.05). Three patients reported adverse drug reactions after consumption of ibuprofen.

Conclusion:

The present study suggested that while managing pain following flap surgery, traumeel was superior as compared to ibuprofen, with minimal or no side effects.

Integrative Medicine in Childhood Cancer

The diagnosis of cancer in a child leaves parents and families devastated and vulnerable. In an effort to do everything possible, families often choose an integrative medicine approach to their child's care. Surveys have found that 31%-84% of children with cancer use complementary and alternative medicine and most often as supportive care agents. Several systematic reviews have demonstrated a clinical benefit for some select therapies; however, the safety and efficacy of the combination of biological therapies with conventional treatment remain largely unknown and garner concern due to the potential for interactions with conventional therapy. Given the sustained use and potential benefit of integrative medicine, additional research is warranted in pediatric oncology. Utilizing the available literature, clinical providers should aim to conduct open and nonjudgmental discussions with families about the use of integrative medicine so as to guide the safe integration of the two modalities.

Integrating Complementary and Traditional Practices in Middle-Eastern Supportive Cancer Care

The Middle East is a promising arena in which researchers can explore the interchange between cross-cultural traditional medicine and supportive cancer care, as provided within an integrative oncology setting. Integrative oncology research and clinical practice in this part of the world have been focusing, for the most part, on the use of herbal medicine and mind-body-spiritual modalities, both of which are deeply rooted in traditional medical care. A regional, multinational, and interdisciplinary collaboration is currently being undertaken as part of the academic activities of the Middle-East Research Group in Integrative Oncology (MERGIO). This group is part of the Middle-East Cancer Consortium, a body supported by the National Cancer Institute. MERGIO currently facilitates a number of innovative educational, basic science, and clinical research projects that are investigating the effectiveness and safety of traditional herbal remedies. In order to create a structured, pragmatic "bedside-to-bench" and subsequent "back-to-bedside" approach, MERGIO has designed a patient-tailored integrative oncology model of supportive-palliative care. This approach addresses both patients' individual health belief models and the larger social-cultural-religious context, as defined by the health-related values of the patient's community.

A systematic review of integrative clinical trials for supportive care in pediatric oncology: a report from the International Society of Pediatric Oncology, T&CM collaborative

PURPOSE

Traditional and complementary medicine (T&CM) use in children with cancer is well established among high-income, upper middle-income, low-middle-income, and low-income countries (HIC, UMIC, LMIC, LIC, respectively). In HIC, a developing body of evidence exists for several T&CM therapies; however, evidence in other income settings is less well described despite a significantly higher use when compared to reports from HIC. The aim of this systematic review was to evaluate the evidence for T&CM for a variety of supportive care indications among children with cancer.

METHODS

We performed a systematic review following the PRISMA guidelines of randomized, controlled clinical trials from inception through September 2016. Our eligibility criteria were limited to T&CM studies performed in children and adolescents undergoing treatment for a pediatric malignancy.

RESULTS

Of 6342 studies identified, 44 met inclusion criteria. Two clinical trials reported on acupuncture, 1 reported on aromatherapy, 9 evaluated massage therapy, and 32 reported on dietary supplements. Twenty-two studies were performed in HIC, 15 in UMIC, and 7 in LMIC. T&CM therapies were most commonly investigated for the prevention or management of mucositis, weight loss, and febrile neutropenia. Encouraging results were reported for select interventions; however, the majority of studies were classified as poor to fair quality.

CONCLUSION

Our search revealed numerous clinical studies investigating the use of T&CM for supportive care purposes in pediatric oncology in HIC, UMIC, and LMIC. Although limited, these results could inform supportive care resource allocation and indicate where T&CM may serve to fill gaps where access to care may be limited.

Model validity of randomised placebo-controlled trials of non-individualised homeopathic treatment

BACKGROUND

The comprehensive systematic review of randomised placebo-controlled trials (RCTs) in homeopathy requires examination of a study's model validity of homeopathic treatment (MVHT) as well as its risk of bias (extent of reliable evidence).

OBJECTIVE

To appraise MVHT in those RCTs of non-individualised homeopathy that an associated investigation had judged as 'not at high risk of bias'.

DESIGN

Systematic review.

METHODS

An assessment of MVHT was ascribed to each of 26 eligible RCTs. Another 49 RCTs were ineligible due to their high risk of bias.

MAIN OUTCOME MEASURES

MVHT and the prior risk of bias rating per trial were merged to obtain a single overall quality designation ('high', 'moderate', 'low'), based on the GRADE principle of downgrading.

RESULTS

The trials were rated as 'acceptable MVHT' (N = 9), 'uncertain MVHT' (N = 10) and 'inadequate MVHT' (N = 7); and, previously, as 'reliable evidence' (N = 3) and 'non-reliable evidence' (N = 23). The 26 trials were designated overall as: 'high quality' (N = 1); 'moderate quality' (N = 18); 'low quality' (N = 7).

CONCLUSION

Of the 26 RCTs of non-individualised homeopathy that were judged 'not at high risk of bias', nine have been rated 'acceptable MVHT'. One of those nine studies was designated 'high quality' overall ('acceptable MVHT' and 'reliable evidence'), and is thus currently the only reported RCT that represents best therapeutic practice as well as unbiased evidence in non-individualised homeopathy. As well as minimising risk of bias, new RCTs in this area must aim to maximise MVHT and clarity of reporting.

Oral Mucositis: Melatonin Gel an Effective New Treatment

The current treatment for cervico-facial cancer involves radio and/or chemotherapy. Unfortunately, cancer therapies can lead to local and systemic complications such as mucositis, which is the most common dose-dependent complication in the oral cavity and gastrointestinal tract. Mucositis can cause a considerably reduced quality of life in cancer patients already suffering from physical and psychological exhaustion. However, the role of melatonin in the treatment of mucositis has recently been investigated, and offers an effective alternative therapy in the prevention and/or management of radio and/or chemotherapy-induced mucositis. This review focuses on the pathobiology and management of mucositis in order to improve the quality of cancer patients' lives.

Herbs in Oral Mucositis

Oral mucositis is an inflammatory mucosal destruction as a result of chemotherapy and/or radiation therapy, which in severe cases can impair patients' quality of life. Moreover, mucosal infection and/or systemic involvement due to compromised immunity leads to delay or discontinuation of the treatment. Many strategies and agents have been suggested for the management of this condition. Because of their lower side effects compared to chemical drugs, general interest in evaluating therapeutic effects of herbs has been increased intensively. Herbal plants apply their effect through different mechanisms of action: antioxidant, analgesic, anti-inflammatory, antifungal, antiseptic, and anticarcinogenic activity. Recently, various natural agents in plants have been noticed in mucositis, which may improve the symptoms through different interventions. The purpose of this review is to focus on the preventive or therapeutic use of herbal medicine to alleviate oral mucositis.

Add-On Complementary Medicine in Cancer Care: Evidence in Literature and Experiences of Integration

Background: According to the literature an increasing number of cancer patients demand for complementary therapies during their disease. Research has demonstrated that some of these therapies are effective and safe as adjunctive treatments in specific symptoms of these patients. Methods: The aims of the paper are to review the main and recent papers of international literature on the effectiveness of complementary medicine (CM) therapies on side effects of anti-cancer protocols and improvement in the quality of life of oncological patients, and to describe the integration of evidence-based acupuncture, herbal medicine and homeopathy treatments in Public Cancer Network of the region of Tuscany. Results: After the review of literature and the approval of a Regional Resolution, some CM will be introduced in Cancer Departments in Tuscany to additionally treat cancer-related symptoms and side effects of conventional cancer therapy: acupuncture for nausea and post-chemotherapy and post-surgery vomiting, pain, hot flashes of iatrogenic menopause, xerostomia; homeopathy for hot flashes of iatrogenic menopause and the side effects of radiotherapy; herbal medicine for cancer-related fatigue, nausea and vomiting, pain, mucositis, anxiety, and depression. Conclusions: The integration of evidence-based complementary treatments allows for an effective response to the demand coming from cancer patients and combines safety and equity of access in public health systems.

A Multidisciplinary Review of Nutrition Considerations in the Pediatric Oncology Population: A Perspective From Children's Oncology Group

Over the past few decades, great progress has been made in the survival rates of childhood cancer. As survival rates have improved, there has been an increased focus on supportive care. Nutrition is a supportive-care modality that has been associated with improved tolerance to chemotherapy, improved survival, increased quality of life, and decreased risk of infection in children undergoing anticancer therapy. Guidelines and assessment criteria have been proposed for the nutrition management of a child with cancer; however, there is no consistent use of criteria among institutions treating children with cancer. This review will present the current evidence and standards of practice incorporating aspects of nutrition, nursing, pharmacology, and psychosocial challenges to consider in the nutrition management of a child with cancer. Recommendations for clinical practice are presented.

Preventive Intervention Possibilities in Radiotherapy- and Chemotherapy-induced Oral Mucositis: Results of Meta-analyses

The aim of these meta-analyses was to evaluate the effectiveness of interventions for the prevention of oral mucositis in cancer patients treated with head and neck radiotherapy and/or chemotherapy, with a focus on randomized clinical trials. A literature search was performed for reports of randomized controlled clinical studies, published between 1966 and 2004, the aim of which was the prevention of mucositis in cancer patients undergoing head and neck radiation, chemotherapy, or chemoradiation. The control group consisted of a placebo, no intervention, or another intervention group. Mucositis was scored by either the WHO, the National Cancer Institute-Common Toxicity Criteria (NCI-CTC) score, or the absence or presence of ulcerations, or the presence or absence of grades 3 and 4 mucositis. The meta-analyses included 45 studies fulfilling the inclusion criteria, in which 8 different interventions were evaluated: i.e., local application of chlorhexidine; iseganan; PTA (polymyxin E, tobramycine, and amphotericin B); granulocyte macrophage-colony-stimulating factor/granulocyte colony-stimulating factor (GM-CSF/G-CSF); oral cooling; sucralfate and glutamine; and systemic administration of amifostine and GM-CSF/G-CSF. Four interventions showed a significant preventive effect on the development or severity of oral mucositis: PTA with an odds ratio (OR) = 0.61 (95% confidence interval [CI], 0.39–0.96); GM-CSF, OR = 0.53 (CI: 0.33–0.87); oral cooling, OR = 0.3 (CI: 0.16–0.56); and amifostine, OR = 0.37 (CI: 0.15–0.89). To date, no single intervention completely prevents oral mucositis, so combined preventive therapy strategies seem to be required to ensure more successful outcomes.

An Approach to Teaching Physicians about Complementary Medicine in the Treatment of Cancer

In recent years, complementary and alternative medicine (CAM) has become popular with the general public. Many cancer patients use CAM, usually without their physicians’ knowledge. The importance of discussing CAM with cancer patients is increasingly acknowledged. Unfortunately, there is little information available about teaching and increasing physicians’ knowledge about these therapies. In a preliminary trial addressing this lack of information, a course about the role of CAM in the treatment of cancer was designed and administered to primary care physicians. The course evolved as a response to an interest that was acknowledged among practicing family physicians and residents. The course involved family physicians, patients, and CAM practitioners. The main focus of the course was to enhance physicians’ understanding and attentiveness to patients’ reasons for using CAM, as well as education about the variety of CAM practices patients are using. The course consisted of biweekly meetings in which practitioners and patients brought their experience and practice. The course outcome was evaluated with an analysis of precourse and postcourse questionnaires. After completing the course, the participants reported that they were more open and able to talk about CAM with their patients and that they felt more prepared to treat patients with cancer, in general. This introductory course appears to be a first step in bridging some of the gaps between the popularity of CAM among cancer patients and primary care physicians’ knowledge related to CAM in cancer care.

Models for the Study of Whole Systems

This article summarizes a network and complex systems science model for research on whole systems of complementary and alternative medicine (CAM) such as homeopathy and traditional Chinese medicine. The holistic concepts of networks and nonlinear dynamical complex systems are well matched to the global and interactive perspectives of whole systems of CAM, whereas the reductionistic science model is well matched to the isolated local organ, cell, and molecular mechanistic perspectives of pharmaceutically based biomedicine. Whole systems of CAM are not drugs with specific actions. The diagnostic and therapeutic approaches of whole systems of CAM produce effects that involve global and patterned shifts across multiple subsystems of the person as a whole. For homeopathy, several characteristics of complex systems, including the probabilistic nature of attractor patterns, variable sensitivity of complex systems to initial conditions, and emergent behaviors in the evolution of a system in its full environmental context over time, could help account for the mixed basic science and controlled clinical trial research findings, in contrast with the consistently positive outcomes of observational studies in the literature. Application of theories and methods from complex systems and network science can open a new era of advances in understanding factors that lead to good versus poor individual global outcome patterns and to rational triage of patients to one type of care over another. The growing reliance on complex systems thinking and systems biology for cancer research affords a unique opportunity to bridge between the CAM and conventional medical worlds with some common language and conceptual models.

Complementary and Alternative Medicine Research and Cooperative Groups: Can It Happen?

The use of complementary and alternative medicine (CAM) interventions to ameliorate cancer- and treatment-related toxicities is gaining increasing attention among clinical investigators. The National Cancer Institute supports a number of clinical studies, both descriptive and interventional, of CAM interventions across the cancer trajectory, from prevention through diagnosis and treatment, survivorship, and end of life. This report highlights the unique challenges that clinical investigators face when designing and implementing CAM clinical trials through the cooperative groups. This report focuses on 2 CAM trials that opened and accrued participants in the Children’s Oncology Group. One trial is aimed at preventing or reducing mucositis and the other at preventing chemotherapy- induced nausea and vomiting.

Symptom Management Research in Children With Cancer

A review of the clinical research studies published within the past 5 years revealed that efforts to manage symptoms of cancer and its treatments have not kept pace with new advances in the cure for cancer. Children with cancer continue to experience distressing physical symptoms caused by the disease and treatment. The purpose of this article is to provide a concise overview of the most common symptoms experienced by children with cancer. These symptoms include pain, nausea and vomiting, nutritional concerns, mucositis, and fatigue experienced by the child with cancer. Recommendations for future research are addressed.

A perspective on complementary/alternative medicine use among survivors of hematopoietic stem cell transplant: Benefits and uncertainties

The widespread use of complementary and alternative medicine (CAM) in cancer survivors is well known despite a paucity of scientific evidence to support its use. The number of survivors of hematopoietic stem cell transplant (HCT) is growing rapidly and HCT clinicians are aware that many of their patients use CAM therapies consistently. However, due to a paucity of data regarding the benefits and harms of CAM therapies in these survivors, clinicians are reluctant to provide specific recommendations for or against particular CAM therapies. A systematic literature review was conducted with a search using PubMed, the Cochrane Database of Systematic Reviews, and Ovid online for each CAM therapy as defined by the National Center of Complementary and Alternative Medicine. The search generated 462 references, of which 26 articles were deemed to be relevant for the review. Due to extensive heterogeneity in data and limited randomized trials, a meta-analysis could not be performed but a comprehensive systematic review was conducted with specified outcomes for each CAM therapy. In randomized controlled trials, certain mind and body interventions such as relaxation were observed to be effective in alleviating psychological symptoms in patients undergoing HCT, whereas the majority of the other CAM treatments were found to have mixed results. CAM use is an understudied area in HCT survivorship and clinicians should convey the benefits and uncertainties concerning the role of CAM therapies to their patients.

Medicinal plants contain mucilage used in traditional Persian medicine (TPM)

CONTEXT

Conventional therapies using mucilage plants greatly used by practitioners in Iran. The usage of mucilages is rooted in traditional knowledge with a history of more than 4000 years. Scientific assessment of these historical documents could be valuable for finding new potential usage in the current medicine.

OBJECTIVE

This study assembled an inventory of mucilage plants considered important therapeutic aids for alleviating the ailments in ancient Persian medicine and compared therapeutic applications of ancient times with current findings of medicinal mucilages in the same plant species.

METHODS

A literature search compiled some main traditional manuscripts of Persian medicine, including the book of AlHavi, Canon of Medicine, Zakhireh-iKharazmshahi, Qarabadine-kabir, Tohfat ol Moemenin, and Makhzan-ol-advieh, and select mucilage plants used in treating the mouth and respiratory system disorders. Also, current investigations on related subjects were considered through a search of the Pub Med and Google Scholar databases.

RESULTS

In Iran, the application of medicinal plants contains mucilage date back to ancient times. In mentioned medieval Persian books, 20 medicinal plants containing mucilage were identified. Mucilages have been traditionally used via oral or topical routes for a variety of disorders. According to this study, most of the cited medicinal plant species were used for their mucilaginous, anti-inflammatory, and anti-oxidant effects.

CONCLUSIONS

A scientific evaluation of these historical documents can give an insight into the ideas of the past and be valuable in finding new data on clinical use of the mucilages that should lead to future opportunities to investigate their potential medicinal use.

Open-label uncontrolled pilot study to evaluate complementary therapy with Ruta graveolens 9c in patients with advanced cancer

BACKGROUND

Patients with advanced metastatic disease are often treated aggressively with multiple lines of chemotherapy, even in the last month of life. The benefit of such an approach remains uncertain. The objective of the study was to investigate whether Ruta graveolens 9c homeopathic medicine can improve quality of life (QoL) and tumour progression in patients with advanced cancer.

MATERIAL AND METHODS

This was a single-centre, open-label, uncontrolled, pilot study. Patients (>18-years, life-expectancy ≥3 months, performance status ≤2) with locally-advanced solid tumours or metastases, previously treated with all available standard anti-cancer treatments were recruited. Oral treatment consisted of two 1-mL ampoules of Ruta graveolens (9c dilution) given daily for a minimum of 8 weeks, or until tumour and/or clinical progression. Primary outcome was QoL measured using the EORTC QLQ-C30 questionnaire. Secondary outcome measures were anxiety/depression measured using the Hospital Anxiety and Depression Scale (HADS), WHO performance status (PS), tumour progression assessed using RECIST criteria and tumour markers, survival and tolerance.

RESULTS

Thirty-one patients were included (mean age: 64.3 years). Mean duration of treatment was 3.3 months (median: 2.1). QoL global health status improved significantly between baseline and week 8 (P < 0.001) and week 16 (P = 0.035), but was at the limit of significance (P = 0.057) at the end of the study. There was no significant change in anxiety/depression or PS during treatment. Ruta graveolens 9c had no obvious effect on tumour progression. Median survival was 6.7 months [95%CI: 4.8-14.9]. Ruta graveolens 9c was well-tolerated.

CONCLUSION

Some patients treated with Ruta graveolens 9c had a transitory improvement in QoL, but the effectiveness of this treatment remains to be confirmed in further studies.

Integrative oncology: really the best of both worlds?

Over the past two decades there has been a growing acceptance of 'integrative oncology', also known as complementary and alternative medicine (CAM), in cancer care and research at academic medical centres and medical schools. Proponents of integrative oncology argue that it is based in science and provides the 'best of both worlds' by combining science-based treatments and 'holistic' medicine. However, a close examination of the methodologies indicates that, from a standpoint of basic science, the vast majority of 'integrative' treatments are supported by little, if any, scientific evidence. What are the consequences of this integration? Is there any harm? Are there any potential benefits?

Integrative nanomedicine: treating cancer with nanoscale natural products

Finding safer and more effective treatments for specific cancers remains a significant challenge for integrative clinicians and researchers worldwide. One emerging strategy is the use of nanostructured forms of drugs, vaccines, traditional animal venoms, herbs, and nutraceutical agents in cancer treatment. The recent discovery of nanoparticles in traditional homeopathic medicines adds another point of convergence between modern nanomedicine and alternative interventional strategies. A way in which homeopathic remedies could initiate anticancer effects includes cell-to-cell signaling actions of both exogenous and endogenous (exosome) nanoparticles. The result can be a cascade of modulatory biological events with antiproliferative and pro-apoptotic effects. The Banerji Protocols reflect a multigenerational clinical system developed by homeopathic physicians in India who have treated thousands of patients with cancer. A number of homeopathic remedy sources from the Banerji Protocols (eg, Calcarea phosphorica; Carcinosin-tumor-derived breast cancer tissue prepared homeopathically) overlap those already under study in nonhomeopathic nanoparticle and nanovesicle tumor exosome cancer vaccine research. Past research on antineoplastic effects of nano forms of botanical extracts such as Phytolacca, Gelsemium, Hydrastis, Thuja, and Ruta as well as on homeopathic remedy potencies made from the same types of source materials suggests other important overlaps. The replicated finding of silica, silicon, and nano-silica release from agitation of liquids in glassware adds a proven nonspecific activator and amplifier of immunological effects. Taken together, the nanoparticulate research data and the Banerji Protocols for homeopathic remedies in cancer suggest a way forward for generating advances in cancer treatment with natural product-derived nanomedicines.

Commonly used methods of complementary medicine in the treatment of breast cancer

Many patients with cancer look for information on complementary or alternative medicine (CAM) and use various CAM methods. Women with breast cancer are amongst the most avid users. Patients in Europe prefer drug-bound CAM methods, which are prone to side effects and drug interactions. In order to reduce these risks, communication between the patient and the physician on CAM is indispensible. Yet, most patients do not discuss CAM in general and complementary drug therapy in particular with their oncologists and most oncologists themselves are not overly familiar with the topic. This article gives an overview on the most often used CAM methods with regard to breast cancer. The current state of the scientific evidence, the benefits and risks are summarized.

Dental Practice Scenario in a Government Homeopathic Hospital in West Bengal, India

This pilot investigation initiated a research-targeted systematic dental homeopathy data collection in the dental outpatient section in a government homeopathic hospital in West Bengal, India. One conventionally trained dentist and 3 homeopathic doctors collected data from 949 appointments of 411 patients over 3 months. A specifically designed Excel spreadsheet enabled recording of consecutive dental appointments that was subjected to data synthesis and analysis in the end. A total of 87.3% conditions were chronic, and chronic periodontitis was most frequent (27.5%). Positive outcome was observed in 72.3% appointments. Strongly positive outcomes (scores of +2 or +3) were achieved most notably in toothache (84.6%). Single medicines were prescribed in 83.5% encounters, and mostly in tincture form (29.9%). Arnica montana constituted of 17.8% prescriptions. Considerable insight was gained into the homeopathic dental practice scenario in West Bengal, India. Positive findings suggest that dental homeopathy is a promising area for research in near future.

Homeopathic medications as clinical alternatives for symptomatic care of acute otitis media and upper respiratory infections in children

The public health and individual risks of inappropriate antibiotic prescribing and conventional over-the-counter symptomatic drugs in pediatric treatment of acute otitis media (AOM) and upper respiratory infections (URIs) are significant. Clinical research suggests that over-the-counter homeopathic medicines offer pragmatic treatment alternatives to conventional drugs for symptom relief in children with uncomplicated AOM or URIs. Homeopathy is a controversial but demonstrably safe and effective 200-year-old whole system of complementary and alternative medicine used worldwide. Numerous clinical studies demonstrate that homeopathy accelerates early symptom relief in acute illnesses at much lower risk than conventional drug approaches. Evidence-based advantages for homeopathy include lower antibiotic fill rates during watchful waiting in otitis media, fewer and less serious side effects, absence of drug-drug interactions, and reduced parental sick leave from work. Emerging evidence from basic and preclinical science research counter the skeptics' claims that homeopathic remedies are biologically inert placebos. Consumers already accept and use homeopathic medicines for self care, as evidenced by annual US consumer expenditures of $2.9 billion on homeopathic remedies. Homeopathy appears equivalent to and safer than conventional standard care in comparative effectiveness trials, but additional well-designed efficacy trials are indicated. Nonetheless, the existing research evidence on safety supports pragmatic use of homeopathy in order to “first do no harm” in the early symptom management of otherwise uncomplicated AOM and URIs in children.

The need for evidence based nutritional guidelines for pediatric acute lymphoblastic leukemia patients: acute and long-term following treatment

High survival rates for pediatric leukemia are very promising. With regard to treatment, children tend to be able to withstand a more aggressive treatment protocol than adults. The differences in both treatment modalities and outcomes between children and adults make extrapolation of adult studies to children inappropriate. The higher success is associated with a significant number of children experiencing nutrition-related adverse effects both in the short and long term after treatment. Specific treatment protocols have been shown to deplete nutrient levels, in particular antioxidants. The optimal nutrition prescription during, after and long-term following cancer treatment is unknown. This review article will provide an overview of the known physiologic processes of pediatric leukemia and how they contribute to the complexity of performing nutritional assessment in this population. It will also discuss known nutrition-related consequences, both short and long term in pediatric leukemia patients. Since specific antioxidants have been shown to be depleted as a consequence of therapy, the role of oxidative stress in the pediatric leukemia population will also be explored. More pediatric studies are needed to develop evidence based therapeutic interventions for nutritional complications of leukemia and its treatment.

Systematic review of natural agents for the management of oral mucositis in cancer patients

PURPOSE

The aim of this study was to review the available literature and define clinical practice guidelines for the use of natural agents for the prevention and treatment of oral mucositis.

METHODS

A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology. The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, and no guideline possible.

RESULTS

A total of 49 papers across 15 interventions were examined. A new suggestion was developed in favor of systemic zinc supplements administered orally in the prevention of oral mucositis in oral cancer patients receiving radiation therapy or chemoradiation (Level III evidence). A recommendation was made against the use of intravenous glutamine for the prevention of oral mucositis in patients receiving high-dose chemotherapy prior to hematopoietic stem cell transplant (Level II evidence). No guideline was possible for any other agent, due to inadequate and/or conflicting evidence.

CONCLUSIONS

Of the various natural agents reviewed here, the available evidence supported a guideline only for two agents: a suggestion in favor of zinc and a recommendation against glutamine, in the treatment settings listed above. Well-designed studies of other natural agents are warranted.

We and they in the house of healing: debate among Arab complementary medicine practitioners on an integrative versus alternative approach to supportive cancer care

PURPOSE

Complementary and traditional medicine (CTM) plays an important role in culture-centered care for cancer patients in the Middle East. In this article, we have studied the attitudes of Arab CTM therapists concerning integration of complementary medicine within the conventional supportive cancer care of Arab patients in northern Israel.

METHODS

Semistructured interviews were held with 27 Arab therapists who use medicinal herbs, the Quran, and various CTM modalities, with the aim of characterizing their treatment practices and learning about their perspectives regarding conventional cancer care.

RESULTS

We first summarized the different characteristics of the various CTM therapists, including training, typical practice, and so on. Thematic analysis revealed that folk healers and complementary medicine therapists describe their role as supportive and secondary to that of physicians. Their goal was not to cure patients with cancer but rather to enhance their quality of life by reducing the severity of both the disease symptoms and the side effects of cancer treatment. Religious healers, by contrast, purport to cure the disease. While folk healers opt for parallel alternative care and complementary therapists support integrative care, religious healers claimed that they offer an alternative to conventional medicine in terms of both etiology and practice.

CONCLUSIONS

The majority of Arab CTM therapists support integration of their treatments with the conventional system, but in practice, they are not sure how to bring about this change or create a parallel model in which 2 different systems are active, but not integrated. Our findings emphasized the need to promote doctor-CTM practitioner communication based on structured referral and bidirectional consultation. Moreover, we recommend intensifying research on the efficacy and safety of CTM in the Middle East and the potential role in promoting culture-based supportive care.