Complimentary Therapies for Cancer– Digest – June 1, 2015

Our current literature update includes:


Genc F; Tan M.
The effect of acupressure application on chemotherapy-induced nausea, vomiting, and anxiety in patients with breast cancer.
Palliative & Supportive Care. 13(2):275-84, 2015 Apr.
OBJECTIVE: The purpose of this study was to determine the effect of
acupressure applied to the pericardium 6 (P6 or neiguan) acupuncture point on chemotherapy-induced nausea, vomiting, and anxiety in patients with breast cancer.
METHOD: The study was conducted using a quasi-experimental model with a control group. It included a total of 64 patients with stages 1-3 breast cancer who received cycle two and more advanced chemotherapy in an ambulatory chemotherapy unit. There were 32 patients in the experimental group and 32 patients in the control group. Acupressure was applied to the P6 acupuncture point of patients in the experimental group with the help of a wristband. A Patient Information Form, the Beck Anxiety Inventory, and the Index of Nausea, Vomiting and Retching were employed to collect the data.
RESULTS: It was determined that the mean nausea, vomiting, and retching scores, the total (experience, occurrence, and distress) scores, and the mean anxiety scores for patients to whom acupressure was applied at the P6 acupuncture point were statistically significantly lower compared with the scores of patients in the control group.
SIGNIFICANCE OF RESULTS: The efficacy of applying acupressure was
demonstrated. We determined that applying acupressure at the P6 point is effective in decreasing chemotherapy-induced nausea, vomiting, and anxiety in patients with breast cancer. Further research with more subjects is needed.

Beikmoradi A; Najafi F; Roshanaei G; Pour Esmaeil Z; Khatibian M; Ahmadi A.
Acupressure and anxiety in cancer patients.
Iranian Red Crescent Medical Journal. 17(3):e25919, 2015 Mar.
BACKGROUND: Anxiety has negative effects on mental and physical performance, quality of life, duration of hospitalization, and even on the treatment of patients with cancer.
OBJECTIVES: Today acupressure is widely used to treat anxiety. Thus, the present study aimed to investigate the effects of acupressure on anxiety in patients with cancer.
PATIENTS AND METHODS: A double-blind randomized clinical trial was conducted on 85 patients hospitalized with 3 groups including acupressure group (n = 27), sham group (n = 28), and control group (n = 30) in the hematologic ward of Shahid Beheshti Hospital of Hamadan, Iran, in 2013. The sampling permuted-block randomization with triple block was used. The anxiety of the patients in the experimental, sham, and control groups were measured with Spielberger's State-Trait Anxiety Inventory (STAI). Then, real acupressure was performed in the experimental group and fake acupressure in the sham group, and only routine care was provided for the control group. Anxiety of the patients was also assessed at 5 and 10 days after the intervention. Statistical analysis of the data was performed by SPSS software using repeated measures analysis of variance (ANOVA) and post hoc least significant difference (LSD) test.
RESULTS: According to the findings, the mean level of anxiety before the intervention between groups were matched (P > 0.05). Acupressure had a significant influence on the anxiety in the experimental group at 5 (45.30 +/- 7.14) and 10 days (43.48 +/- 6.82) after the intervention (P < 0.05). However, it did not have a significant impact on their covert anxiety (45.48 +/- 7.92 at 5(th) day vs 45.63 +/- 8.08 at 10th day, P > 0.05). No significant differences were observed in the fake points regarding overt and covert anxiety of patients in the sham group (overt anxiety; 47.57 +/- 7.85 at 5(th) day vs. 46.71 +/- 7.32 at 10(th) day, P > 0.05) (covert anxiety; 47.96 +/- 6.33 at 5(th) day vs. 46.89 +/- 6.94 at 10(th) day, P > 0.05). Moreover, the routine care provided for the control group did not have any effect on the overt and covert anxiety of the patients (P > 0.05).
CONCLUSIONS: Acupressure is recommended as a complementary therapy to reduce anxiety in patients with cancer because of its low cost, safety, and simplicity.

Commentary by Weidong Lu, MPH, PhD
Acupressure and anxiety in cancer patients
Summary: This study is a double-blind randomized clinical trial testing acupressure in cancer patients with anxiety. In this study, 90 cancer patients were randomized into 3 groups: the active acupressure group; the sham acupressure group and the control group (the usual care without acupressure). The active acupressure was given on 9 acupuncture points (14 sites) for 20-30 min. each session, one session per day for 10 days. The sham acupressure was given on sham points that were 2 cm away from the points of the active acupressure group. The control group was offered routine care only. The patients were assessed with The State-Trait Anxiety Inventory (STAI), a commonly used measure of trait and state anxiety, before and after the intervention. The results shows that at the end of the study, the mean difference of state anxiety score was significantly lower in both the active acupressure group and the sham acupressure group than that in the control group (-5.90 ± 1.70, p=0.001, -4.54 ± 1.68, p=0.009, respectively); however, no statistical significance was found between the active acupressure group and the sham acupressure group.
Commentary: Acupressure is a type of therapy using hands or elbows pressing on acupoints for treatment. People often refer to acupressure as an extension of acupuncture without using needles. Actually, acupressure in a way is much closer to massage than acupuncture since acupressure uses physical pressure and hand manipulation on a relatively large surface of skin to achieve therapeutic effects, while acupuncture uses sharp needles to precisely stimulate acupoints and deep tissue structures, with much less physical pressure but much more profound and lasting physiological effects. Acupressure holds unique advantage because it is low cost, safe and simple to use. This study is a well-conducted study using an appropriate design. The data suggests that both active acupressure and sham acupressure reduce state anxiety in cancer patients, but no differences were found between them, suggesting either a strong placebo effect exists or the acupoints used were not functionally specific.
Unfortunately, the study did not give details about how the acupressure was actually performed and how much pressure was applied on the real acupoints and the sham sites. Without measurement of pressure used, it is difficult to interpret the results observed in the study. Since the training background and experience of practitioners are an important part of the study outcomes, it is critical to provide information of participating practitioners. In addition, pharmaceutical drugs such as corticosteroids, often used by cancer patients, may very likely affect state anxiety during the study period. Unfortunately, the study did not measure confounding effects of drugs on anxiety. Overall, the study shows that acupressure may be beneficial to cancer patients with anxiety but it is premature to "recommend" the therapy as the authors concluded. More studies are needed.

Treatments for Aromatse-Inhibitor Induced Arthralgias
Chien TJ; Liu CY; Chang YF; Fang CJ; Hsu CH.
Acupuncture for treating aromatase inhibitor-related arthralgia in breast cancer: a systematic review and meta-analysis.
Journal of Alternative & Complementary Medicine. 21(5):251-60, 2015 May.
PURPOSE: Acupuncture has been used as a complementary medical treatment for arthralgia and other types of pain. The objective of this review is to assess the effectiveness of acupuncture in the treatment of arthralgia in patients with breast cancer who were treated with aromatase inhibitors (AIs).
METHODS: A literature search was performed, without language restrictions, of 10 databases from their inception through February 2014. The literature reviewed included randomized clinical trials (RCTs) and clinical trials that compared real versus sham acupuncture for the treatment of AI-related musculoskeletal symptoms (AIMSS). The methodologic quality of these trials was assessed by using the modified Jadad Quality Scale. Meta-analytic software (RevMan 5.0) was used to analyze the data.
RESULTS: Five To compare the effects of real versus sham acupuncture, five RCTs were assessed by meta-analysis and quality analysis. Three of the RCTs reported favorable effects with regard to use of acupuncture in reducing pain and joint-related symptoms, while the other two RCTs did not. The meta-analysis showed trends toward reduced pain and stiffness in patients given acupuncture compared with those who received sham treatment (n=82; pain, mean difference: -2.07 [95% confidence interval (CI), -4.72 to 0.57]; p=0.12; stiffness, mean difference: -86.10 [95% CI, -249.11 to 76.92]; p=0.30), although these differences were not statistically significant.
CONCLUSIONS: Acupuncture has been reported as a safe and promising treatment for AIMSS, but the present analysis indicated that the effects were not statistically significant. Other outcome measurements, such as imaging studies, would be worth including in future studies to further confirm the efficacy of acupuncture in AIMSS.

Dawn L. Hershman⇑, Joseph M. Unger, Katherine D. Crew, Danielle Awad, Shaker R. Dakhil, Julie Gralow, Heather Greenlee, Danika L. Lew, Lori M. Minasian, Cathee Till, James L. Wade III, Frank L. Meyskens and Carol M. Moinpour
Randomized Multicenter Placebo-Controlled Trial of Omega-3 Fatty Acids for the Control of Aromatase Inhibitor–Induced Musculoskeletal Pain: SWOG S0927
JCO.2014.59.5595; published online onMay 4, 2015;
Purpose Musculoskeletal symptoms are the most common adverse effects of aromatase inhibitors (AIs) and can result in decreased quality of life and discontinuation of therapy. Omega-3 fatty acids (O3-FAs) can be effective in decreasing arthralgia resulting from rheumatologic conditions and reducing serum triglycerides.
Patients and Methods Women with early-stage breast cancer receiving an AI who had a worst joint pain/stiffness score ≥ 5 of 10 using the Brief Pain Inventory–Short Form (BPI-SF) were randomly assigned to receive either O3-FAs 3.3 g or placebo (soybean/corn oil) daily for 24 weeks. Clinically significant change was defined as ≥ 2-point drop from baseline. Patients also completed quality-of-life (Functional Assessment of Cancer Therapy–Endocrine Symptoms) and additional pain/stiffness assessments at baseline and weeks 6, 12, and 24. Serial fasting blood was collected for lipid analysis.
Among 262 patients registered, 249 were evaluable, with 122 women in the O3-FA arm and 127 in the placebo arm. Compared with baseline, the mean observed BPI-SF score decreased by 1.74 points at 12 weeks and 2.22 points at 24 weeks with O3-FAs and by 1.49 and 1.81 points, respectively, with placebo. In a linear regression adjusting for the baseline score, osteoarthritis, and taxane use, adjusted 12-week BPI-SF scores did not differ by arm (P = .58). Triglyceride levels decreased in patients receiving O3-FA treatment and remained the same for those receiving placebo (P = .01). No between-group differences were seen for HDL, LDL, or C-reactive protein.
We found a substantial (> 50%) and sustained improvement in AI arthralgia for both O3-FAs and placebo but found no meaningful difference between the groups.

Peppone LJ; Janelsins MC; Kamen C; Mohile SG; Sprod LK; Gewandter JS; Kirshner JJ; Gaur R; Ruzich J; Esparaz BT; Mustian KM.
The effect of YOCAS; yoga for musculoskeletal symptoms among breast cancer survivors on hormonal therapy.
Breast Cancer Research & Treatment. 150(3):597-604, 2015 Apr.
Up to 50% of breast cancer survivors on aromatase inhibitor therapy report musculoskeletal symptoms such as joint and muscle pain, significantly impacting treatment adherence and discontinuation rates. We conducted a secondary data analysis of a nationwide, multi-site, phase II/III randomized, controlled, clinical trial examining the efficacy of yoga for improving musculoskeletal symptoms among breast cancer survivors currently receiving hormone therapy (aromatase inhibitors [AI] or tamoxifen [TAM]). Breast cancer survivors currently receiving AI (N = 95) or TAM (N = 72) with no participation in yoga during the previous 3 months were randomized into 2 arms: (1) standard care monitoring and (2) standard care plus the 4-week yoga intervention (2x/week; 75 min/session) and included in this analysis. The yoga intervention utilized the UR Yoga for Cancer Survivors (YOCAS©()) program consisting of breathing exercises, 18 gentle Hatha and restorative yoga postures, and meditation. Musculoskeletal symptoms were assessed pre- and post-intervention. At baseline, AI users reported higher levels of general pain, muscle aches, and total physical discomfort than TAM users (all P < 0.05). Among all breast cancer survivors on hormonal therapy, participants in the yoga group demonstrated greater reductions in musculoskeletal symptoms such as general pain, muscle aches and total physical discomfort from pre- to post-intervention than the control group (all P < 0.05). The severity of musculoskeletal symptoms was higher for AI users compared to TAM users. Among breast cancer survivors on hormone therapy, the brief community-based YOCAS© intervention significantly reduced general pain, muscle aches, and physical discomfort. intervention significantly reduced general pain, muscle aches, and physical discomfort.

Commentary by Ting Bao, MD, SIO Research Committee Co-Chair
Aromatase inhibitors (AIs) are first-line hormonal treatment for estrogen receptor-positive breast cancer in postmenopausal women. AI-associated musculoskeletal symptoms (AIMSS) are the most common side effects of AIs and can severely worsen patients' quality of life. Although there is no standard FDA-approved pharmacologic treatment for AIMSS, increased interest in possible integrative oncology modalities has yielded the publication of three articles over the past 2 months evaluating three different approaches: acupuncture, dietary supplementation with omega-3 fatty acids (O3FAs), and yoga.
Hershman et al (O3FAs): Among them, the multicenter double-blind placebo-controlled trial evaluating O3FAs by Hershman et al1 published in Journal of Clinical Oncology generated the most interest in the scientific community. Study results indicate that when 249 breast cancer survivors who suffered from AIMSS pain ≥5 on the Brief Pain Inventory scale of 1–10 were randomized to 24 weeks of daily O3FA supplementation or placebo, both groups experienced clinically significant pain reduction of >50% compared with baseline, but with no significant between-group differences.
Juxtaposed with the finding that O3FA supplementation did not appear to be more effective in reducing AIMSS symptoms than placebo, is the apparent larger-than-usual placebo effect. In addition, without a usual care control arm, it is difficult to determine whether these significant improvements in both arms weren't more attributable to the natural recovery process than placebo. It would also be helpful to know how well patients were blinded and how many stopped AIs or switched hormonal treatment during the trial. Overall, this was a well-conducted study led by a group of experienced researchers. However, an initial pilot study to calculate sample size based on the effect of the placebo pills used may have led to more definitive findings in this large, multicenter trial. Of particular note, the robust recruitment of 262 patients in only 1 year and the high percentage of evaluable patients (95%) speak to the strong interest among cancer survivors to participate in clinical trials involving dietary supplements.
Chien et al (Acupuncture): The systematic review and meta-analysis by Chien et al2 evaluates five pilot randomized controlled trials on the effects of acupuncture in reducing AIMSS. It was the first systematic review in this area, although the authors were only able to conduct a meta-analysis on two of the five trials due to significant differences in trial design and primary endpoints. Among 82 of 207 patients in total, there was a trend toward better pain and stiffness reduction in real acupuncture when compared with sham acupuncture (pain, mean difference: −2.07 [95% confidence interval (CI), −4.72 to 0.57], p=0.12; stiffness, mean difference: −86.10 [95% CI, −249.11 to 76.92], p=0.30).
This systematic review is limited by the heterogeneity of the five pilot studies and is not likely to be practice-changing. The ongoing SWOG study (NCT01535066) with a sample size of 228 patients randomized into three arms (real acupuncture, sham acupuncture, and usual care) should help to further clarify the role of acupuncture in breast cancer survivors with AIMSS.
Peppene et al (yoga): Lastly, Peppone et al3 reported on a post hoc analysis of a yoga and sleep study to evaluate the effects of a specified yoga program on musculoskeletal symptoms in breast cancer survivors taking AIs (n=95) or tamoxifen (n=72). Compared with usual care, the 4-week yoga program significantly reduced musculoskeletal symptoms in these patients. This is the first randomized controlled trial to evaluate the effect of yoga on musculoskeletal symptoms in breast cancer survivors on hormonal treatment.

The conclusions are limited by results generated from post hoc analysis, with the primary endpoint of the study being sleep quality rather than musculoskeletal symptoms. As such, this study did not use the standard questionnaires to assess musculoskeletal symptoms such as the Brief Pain Inventory. Rather, all musculoskeletal symptoms were assessed by extracting answers from questionnaires primarily used to assess other symptoms such as fatigue on a scale of 0 to 4. In addition, as encouraging as it is that most patients in the yoga arm showed symptom improvement, it is not clear whether the magnitude of the improvement meets the definition of clinical significance. Overall, the article is hypothesis-generating and further studies are needed to fully establish the role of yoga in the management of musculoskeletal symptoms associated with hormonal treatment.

Therefore, current research suggests:
• O3FA supplementation does not appear to be more effective in reducing AIMSS than placebo. However, both interventions provided significant benefits and although the placebo effect is quite remarkable, it has not been fully elucidated.
• Acupuncture shows a trend toward reducing AIMSS, although heterogeneous trial designs limited the ability to compare results across all studies. Ongoing research may further clarify its role.
• Yoga maybe effective in reducing musculoskeletal symptoms in breast cancer survivors taking AIs or tamoxifen, but additional studies using AIMSS as the primary endpoint are needed .
It is encouraging that high-quality research such as the O3FA AIMSS trial is emerging, and we would like to strongly recommend that the integrative oncology field conduct more trials like it.

1. Hershman DL, Unger JM, Crew KD, et al: Randomized Multicenter Placebo-Controlled Trial of Omega-3 Fatty Acids for the Control of Aromatase Inhibitor-Induced Musculoskeletal Pain: SWOG S0927. J Clin Oncol 33:1910-7, 2015
2. Chien TJ, Liu CY, Chang YF, et al: Acupuncture for treating aromatase inhibitor-related arthralgia in breast cancer: a systematic review and meta-analysis. J Altern Complement Med 21:251-60, 2015
3. Peppone LJ, Janelsins MC, Kamen C, et al: The effect of YOCAS(c)(R) yoga for musculoskeletal symptoms among breast cancer survivors on hormonal therapy. Breast Cancer Res Treat 150:597-604, 2015

Rao RM; Raghuram N; Nagendra HR; Usharani MR; Gopinath KS; Diwakar RB; Patil S; Bilimagga RS; Rao N.
Effects of an integrated Yoga Program on Self-reported Depression Scores in Breast Cancer Patients Undergoing Conventional Treatment: A Randomized Controlled Trial.
Indian Journal of Palliative Care. 21(2):174-81, 2015 May-Aug.
AIM: To compare the effects of yoga program with supportive therapy on self-reported symptoms of depression in breast cancer patients undergoing conventional treatment.
PATIENTS AND METHODS: Ninety-eight breast cancer patients with stage II and III disease from a cancer center were randomly assigned to receive yoga (n = 45) and supportive therapy (n = 53) over a 24-week period during which they underwent surgery followed by adjuvant radiotherapy (RT) or chemotherapy (CT) or both. The study stoppage criteria was progressive disease rendering the patient bedridden or any physical musculoskeletal injury resulting from intervention or less than 60% attendance to yoga intervention. Subjects underwent yoga intervention for 60 min daily with control group undergoing supportive therapy during their hospital visits. Beck's Depression Inventory (BDI) and symptom checklist were assessed at baseline, after surgery, before, during, and after RT and six cycles of CT. We used analysis of covariance (intent-to-treat) to study the effects of intervention on depression scores and Pearson correlation analyses to evaluate the bivariate relationships.
RESULTS: A total of 69 participants contributed data to the current analysis (yoga, n = 33, and controls, n = 36). There was 29% attrition in this study. The results suggest an overall decrease in self-reported depression with time in both the groups. There was a significant decrease in depression scores in the yoga group as compared to controls following surgery, RT, and CT (P < 0.01). There was a positive correlation (P < 0.001) between depression scores with symptom severity and distress during surgery, RT, and CT.
CONCLUSION: The results suggest possible antidepressant effects with yoga intervention in breast cancer patients undergoing conventional treatment.

Rossi E; Vita A; Baccetti S; Di Stefano M; Voller F; Zanobini A.
Complementary and alternative medicine for cancer patients: results of the EPAAC survey on integrative oncology centres in Europe.
Supportive Care in Cancer. 23(6):1795-806, 2015 Jun.
BACKGROUND: The Region of Tuscany Health Department was included as an associated member in WP7 "Healthcare" of the European Partnership for Action Against Cancer (EPAAC), initiated by the EU Commission in 2009.
AIMS: The principal aim was to map centres across Europe prioritizing those that provide public health services and operating within the national health system in integrative oncology (IO).
METHODS: A cross-sectional descriptive survey design was used to collect data. A questionnaire was elaborated concerning integrative oncology therapies to be administered to all the national health system oncology centres or hospitals in each European country. These institutes were identified by convenience sampling, searching on oncology websites and forums. The official websites of these structures were analysed to obtain more information about their activities and contacts.
RESULTS: Information was received from 123 (52.1 %) out of the 236 centres contacted until 31 December 2013. Forty-seven out of 99 responding centres meeting inclusion criteria (47.5 %) provided integrative oncology treatments, 24 from Italy and 23 from other European countries. The number of patients seen per year was on average 301.2+/-337. Among the centres providing these kinds of therapies, 33 (70.2 %) use fixed protocols and 35 (74.5 %) use systems for the evaluation of results. Thirty-two centres (68.1 %) had research in progress or carried out until the deadline of the
survey. The complementary and alternative medicines (CAMs) more frequently provided to cancer patients were acupuncture 26 (55.3 %), homeopathy 19 40.4 %), herbal medicine 18 (38.3 %) and traditional Chinese medicine 17 36.2 %); anthroposophic medicine 10 (21.3 %); homotoxicology 6 (12.8 %); and other therapies 30 (63.8 %). Treatments are mainly directed to reduce adverse reactions to chemo-radiotherapy (23.9 %), in particular nausea and vomiting (13.4 %) and leucopenia (5 %). The CAMs were also used to reduce pain and fatigue (10.9 %), to reduce side effects of iatrogenic menopause (8.8 %) and to improve anxiety and depression (5.9 %), gastrointestinal disorders (5 %), sleep disturbances and neuropathy (3.8 %).
CONCLUSIONS: Mapping of the centres across Europe is an essential step in the process of creating a European network of centres, experts and professionals constantly engaged in the field of integrative oncology, in order to increase, share and disseminate the knowledge in this field and provide evidence-based practice.

Pourtsidis A; Doganis D; Baka M; Varvoutsi M; Bouhoutsou D; Xatzi P;
Kosmidis H.
Prayer and blessings focused for healing is the most popular complementary intervention in a paediatric oncology unit in Greece.
Journal of B.U.On.. 20(2):602-7, 2015 Mar-Apr. Citation processed from: Print
PURPOSE: Increasing numbers of children with cancer are using complementary and alternative medicine (CAM) therapies. Our aim was to estimate the rate of use, the beliefs of users and non-users and factors related with the use of CAM among Greek families.
METHODS: A self-reported questionnaire was given to parents of 184 children with cancer. We assessed the rate of use, types of CAM therapies and factors potentially associated with the use of CAM.
RESULTS: Based on the 110 questionnaires which were completed (59.8% of the families), 23 families (21%) had used at least one complementary treatment. The most common forms were: spiritual healing/prayer/blessings 18/23 (78%), art therapies 4, dietary supplements 3, massage 3, homeopathy 2, and herbals 2. The reasons given for use included: making the child stronger 17/23 (48%, hope of stopping the cancerous process 11/23 (49%), and coping with side effects 6/23 (26%). Among the reasons given by the parents for not using CAM therapies the most common (84%) was the effective conventional treatment and, therefore, there was no need for CAM use. Another 24% reported that were unaware of these "alternative" and "complementary" therapies and a further 7% had considered using them but finally they didn't. In bivariate analysis, the use of CAM was not associated either with age, sex, nationality, education or occupation of the parents at the time of the survey, or with diagnosis, mode of therapy or age of the child at diagnosis.
CONCLUSIONS: The use of CAM therapies by Greek families for their children with cancer does not appear to be very popular, although the experiences of those who did use them were generally positive.

Ben-Arye E; Hamadeh AM; Schiff E; Jamous RM; Dagash J; Jamous RM; Agbarya A; Bar-Sela G; Massalha E; Silbermann M; Ali-Shtayeh MS.
Compared perspectives of Arab patients in Palestine and Israel on the role of complementary medicine in cancer care.
Journal of Pain & Symptom Management. 49(5):878-84, 2015 May.
CONTEXT: Complementary medicine (CM) is extensively used by patients with cancer across the Middle East.
OBJECTIVES: We aimed to compare the perspectives of two Arab populations residing in diverse socioeconomic-cultural settings in Palestine and Israel regarding the role of CM in supportive cancer care.
METHODS: A 27-item questionnaire was constructed and administered to a convenience sample of Arab patients receiving cancer care in four oncology centers in northern Israel and Palestine.
RESULTS: Each of the two groups had 324 respondents and was equally distributed by age and marital status. Compared with the Israeli-Arab group, Palestinian participants reported gnificantly higher CM use for cancer-related outcomes (63.5% vs. 39.6%, P < 0.001), which included more herbal use (97.6% vs. 87.9%, P = 0.001) and significantly lower use of dietary supplements, acupuncture, mind-body and manual therapies, and homeopathy. Most respondents in both groups stated that they would consult CM providers if CM was integrated in oncology departments. Related to this theoretical integrative scenario, Palestinian respondents expressed fewer expectations from their oncologists to actively participate in building their CM treatment plan. Treatment expectations in both groups focused on improving quality of life (QOL), whereas Palestinian respondents had fewer expectations for CM to improve fatigue, emotional concerns, sleep, and daily functioning.
CONCLUSION: Arab patients with cancer from Palestine and Israel highly support CM integration within their oncology institutions aiming to improve QOL. Nevertheless, respondents differed in their perceived model of CM integration, its treatment objectives, and their oncologists' role.