What difficulties may be expected in the design and implementation of the integrative oncology treatment program, which is tailored to patients' general and specific concerns. In the following session, we will return to the main questions raised regarding the role of herbal medicine use by patients with cancer, primarily within the context of supportive and palliative care. As we have discussed, there are four classical schools of traditional herbal medicine Middle Eastern, Chinese, Indian, and European. Each with its own approach to patient care and perspective of the role of practitioner-patient communication. We also talked about the impact of specific herbs and herbal formulas in the management of symptoms, which may be related to the cancer or to toxic effects of oncology treatments. We addressed general symptoms as they relate to quality of life as well as specific symptoms of the gastrointestinal tract, fatigue, emotional distress, insomnia, and disturbances of pain among others. In this session, we will move to the next and most important stage in which the patient-centered oncology treatment program tailored to general and specific concern is designed. The goal of this stage is to address patients' concerns and expectations, while providing up to date evidence-based guidance on the safe and effective use of herbal products. Earlier in the course, we addressed a number of aspects, which were related to the main concepts associated with a patient-centered approach to cancer care as well as regarding the design of the patient tailored integrative treatment program. The concept of a patient-centered approach to care and patient tailored treatment may sound the same. But, this is not necessarily the case. We asked Professor Adi Haramati, Director of the Center for Innovation and Leadership in Education at Georgetown University Medical Center in Washington, DC, to clarify the difference between these two concepts. Do you perceive any difference between the concept of patient-centered care and patient-tailored treatments? No, I think one flows from the other. So, patient-centered care would say the patient is in the center of the relationship. There's a patient preference, there's the practitioner, there's the learning environment, there's the family, there's psycho-social elements that bear on us. But, then tailoring the right therapy, well, that also requires data, that requires information, for whom, or which group of patients. Is massage better than acupuncture? Does the cultural context matter because that's going to be a very important element with the belief system, and we all know that if a patient believes that a particular therapy would be helpful, that actually improves the outcomes. So, why wouldn't we want to use that? Why wouldn't we will build on that as opposed to forcing a therapy on someone that really doesn't want it, that we know that's not going to be an outcome. So, there's a lot more to be gained by understanding this. There's also an element of the practitioner, developing their empathy. Developing, it's a difficult field to be giving care all the time because what happens is you give and you give, and unless you learn to replenish, unless you learn to understand yourself, and what you need, you're not going to be effective for your patient. So, there's attention line here between giving-giving and also receiving-receiving, and so this is also where integrative medicine can help inform the process by allowing practitioners to use some of these tools for their own benefit, which will make them much more effective with patients. In real life clinical practice, patients are usually referred by their oncologist, oncology nurse, or other healthcare practitioner to the integrative physician consultation. The IP, the Integrative Physician, sits with the patients and together co-design an integrative medicine treatment program, which is based on a patient-centered approach to cancer care. The integrative physician needs to consider many aspects of the therapeutic process, some of which may conflict with one another all the conventional evidence-based paradigm of care. This process separates the integrative care setting to that of alternative medicine. When designing a patient-centered treatment plan, the IP needs to decide where to place the focus of the therapeutic process. Should the integrative plan take disease-oriented approach focusing on the patient's expectations from non-conventional medicine to fight cancer, prevent the disease from spreading or strengthen the immune system? Should the integrative plan B symptom-oriented with a goal of reducing symptoms and improving quality of life related concerns? Should the integrative plan B focus primarily on the oncology treatment regimen? A chemotherapy directed approach or any other approach, which focuses on the toxic effects of specific oncology drugs, for example, neuropathy, caused by taxon agents may also increase patient's ability to adhere to the treatment schedule and dosing. A study conducted in Israel showed that patients undergoing chemotherapy with Paclitaxel, Taxol and Carboplatin who at the same time received integrative treatments, showed a higher rate of adherence measured as the relative dose intensity or RDI to their chemotherapy regimen than patients treated with only standard supportive care. In the following interview, we spoke with Professor Massimo Bonucci, a medical oncologist and surgical pathologist. From Italy, Professor Bonucci spoke about what he sees should be the emphasis when designing a patient-tailored herbal medicine treatment program, which includes addressing the cancer type and chemotherapy agents being administered. We use herbs not all together, but herb about the type of the cancer, but about type of the chemotherapy. Examples. So, you modify the herbs? Yes, of course. According to the chemotherapy? Yes, of course. According to the cancer? Yes, of course. Because, example. When the people take a chemotherapy with platin, since platin, carboplatin, oxaliplatin, I use Aloe vera because the Aloe vera is demonstrated of a study that announced the work of plotting in the cancer cells, and I use. But, if you don't use platin, I don't use Aloe vera. I use Astragalus for lung cancer. For lung cancer. For lung cancer because the Astragalus announced the work of platin in lung cancer, and then I use Astragalus to enhance the results, and is very complicated, but when you know very well the type of the herbs, the type of the chemotherapy for us is quite simple to know how herb use in such type. The cancer as such type of a chemotherapy or radiotherapy too. The IP consultation is based on a four-step approach, which begins with a patient-centered approach to care, and concludes with a patient-tailored integrative treatment plan as discussed earlier. The first step of the consultation is to define the goals of the integrative treatment program. Discuss the patient's expectations from the integrative treatments. Ask for the patient's narrative on their physical, emotional, and spiritual distress and concerns. Address the indications listed by the referring healthcare practitioners, the HCP, and examine the patient's prior experience with non-conventional medicine, within an integrative complementary, or alternative framework including treatments unrelated to the oncology setting. For example, past experience with acupuncture for low back pain. The second step of the IP consultation, addresses the patient's concerns, as well as issues related to their well-being, lifestyle, and health-beliefs from a bio-psycho-social-spiritual perspective. This includes the use of directed questions, as well as patient reported outcome measures or PROMs. The PROM tools are validated and reliable questionnaires used to define the severity of symptoms and concerns, both from a quantitative, as well as qualitative perspective. The third step, is to then list the goals of the integrative treatment program with the patient and then prioritize them according to their importance, while at the same time, trying to create a realistic and feasible target based on the IP's experience and the evidence in the literature. The fourth and final step of the IP consultation entails co-designing an integrative treatment plan with the patient. In our conversation with Dr. Dagash, he described this four-step approach, emphasizing the importance of what he calls, the shared decision-making process. So, you describe the process of formulating the treatment plan as a shared decision-making, I would say. Absolutely. It such a shared and it's kind of we are together in this. Not it's not just my suggestion. Let's do it together. The use of herbal medicine plays a central role in each of the four steps of the IP consultation. In the initial first step, the IP needs to identify past and present experience with non-conventional medicine, including the use of herbal medicine and understand the patient's expectations from this practice, with regard to their disease, immune system, and symptom load. The role of herbal medicine in the patient's lifestyle behavior and health-beliefs will be raised during the second step of the consultation as well, with the IP addressing the effectiveness and safety of herbal remedies during step three. The fourth and final step, the IP together with the patient will co-design the integrative treatment program, which may include the use of herbal medicine. The IP may at this stage alert the patient about specific herbal products, which are not recommended, primarily due to safety related concerns among other reasons. This last step is the most complex, since the integrative physician needs to take the information while understanding the patient's expectations and health-belief model and weave a patient-tailored integrative treatment plan.
