// Massimiliano Berretta 1 , Chiara Della Pepa 2 , Paolo Tralongo 3 , Alberto Fulvi 4 , Ferdinando Martellotta 1 , Arben Lleshi 1 , Guglielmo Nasti 5 , Rossella Fisichella 6 , Carmela Romano 5 , Chiara De Divitiis 5 , Rosaria Taibi 1 , Francesco Fiorica 7 , Raffaele Di Francia 8, 9 , Anna Di Mari 3 , Lino Del Pup 10 , Anna Crispo 11 , Paolo De Paoli 12 , Adriano Santorelli 13 , Vincenzo Quagliariello 5 , Rosario Vincenzo Iaffaioli 5 , Umberto Tirelli 1 , Gaetano Facchini 2 1 Department of Medical Oncology, National Cancer Institute, Aviano (PN), Italy 2 Division of Medical Oncology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Naples, Italy 3 Division of Medical Oncology, “Umberto I” Hospital, Syracuse, Italy 4 Department of Medicine and Surgery of Integrated Treatment, Division of Thoracic Oncology, “San Camillo Forlanini” Hospital, Rome, Italy 5 Department of Abdominal Oncology, Division of Medical Oncology B, National Cancer Institute, “G. Pascale” Foundation, Naples, Italy 6 Department of Surgery, University of Catania, Catania, Italy 7 Department of Radiation Oncology University Hospital Ferrara, Division of Radiotherapy, “Arcispedale Sant’Anna” Hospital, Ferrara, Italy 8 Department of Hematology, Istituto Nazionale Tumori ‘Fondazione Giovanni Pascale’, IRCCS, Naples, Italy 9 Gruppo Oncologico Ricercatori Italiani, GORI, Pordenone, Italy 10 Division of Gynaecological Oncology, National Cancer Institute, Aviano (PN), Italy 11 Unit of Epidemiology, Struttura Complessa di Statistica Medica, Biometria e Bioinformatica, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Naples, Italy 12 Scientific Directorate, National Cancer Institute, Aviano (PN), Italy 13 Department of Plastic Surgery, Regenerative Medicine, Health Park Hospital, Naples, Italy Correspondence to: Massimiliano Berretta, email: mberretta@cro.it Keywords: complementary medicine, alternative medicine, survey, cancer, treatment Received: October 13, 2016      Accepted: November 20, 2016      Published: December 25, 2016 ABSTRACT Introduction: Complementary and Alternative Medicine (CAM) include a wide range of products (herbs, vitamins, minerals, and probiotics) and medical practices, developed outside of the mainstream Western medicine. Patients with cancer are more likely to resort to CAM first or then in their disease history; the potential side effects as well as the costs of such practices are largely underestimated. Patients and method: We conducted a descriptive survey in five Italian hospitals involving 468 patients with different malignancies. The survey consisted of a forty-two question questionnaire, patients were eligible if they were Italian-speaking and receiving an anticancer treatment at the time of the survey or had received an anticancer treatment no more than three years before participating in the survey. Results: Of our patients, 48.9% said they use or have recently used CAM. The univariate analysis showed that female gender, high education, receiving treatment in a highly specialized institute and receiving chemotherapy are associated with CAM use; at the multivariate analysis high education (Odds Ratio, (OR): 1.96 95% Confidence Interval, CI, 1.27-3.05) and receiving treatment in a specialized cancer center (OR: 2.75 95% CI, 1.53-4.94) were confirmed as risk factors for CAM use. Conclusion: Roughly half of our patients receiving treatment for cancer use CAM. It is necessary that health professional explore the use of CAM with their cancer patients, educate them about potentially beneficial therapies in light of the limited available evidence of effectiveness, and work towards an integrated model of health-care provision.

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Use of Complementary and Alternative Medicine (CAM) in cancer patients: An Italian multicenter survey

BACKGROUND
The authors assessed the use of herbal medicine by Middle Eastern patients with cancer, as reported by their oncology health care professionals (HCPs). Herbal products identified by the study HCPs were evaluated for potential negative effects.

METHODS
Oncology HCPs from 16 Middle Eastern countries received a 17-item questionnaire asking them to list 5 herbal products in use by their patients with cancer. A literature search (PubMed, Micromedex, AltMedDex, and the Natural Medicine Comprehensive Database) was conducted to identify safety-related concerns associated with the products listed.

RESULTS
A total of 339 HCPs completed the study questionnaire (response rate of 80.3%), identifying 44 herbal and 3 nonherbal nutritional supplements. Safety-related concerns were associated with 29 products, including herb-drug interactions with altered pharmacodynamics (15 herbs), direct toxic effects (18 herbs), and increased in vitro response of cancer cells to chemotherapy (7 herbs).

CONCLUSIONS
Herbal medicine use, which is prevalent in Middle Eastern countries, has several potentially negative effects that include direct toxic effects, negative interactions with anticancer drugs, and increased chemosensitivity of cancer cells, requiring a reduction in dosedensity. Oncology HCPs working in countries in which herbal medicine use is prevalent need to better understand the implications of this practice. The presence of integrative physicians with training in complementary and traditional medicine can help patients and their HCPs reach an informed decision regarding the safety and effective use of these products. Cancer 2016;122:598–610. © 2015 American Cancer Society.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/cncr.29796

Potential risks associated with traditional herbal medicine use in cancer care: A study of Middle Eastern oncology health care professionals

Plants have been the primary source of medicines since life on earth; more than 50 % of existing cancer treatments are derived from plants. An ethnopharmacological survey of herbal remedies used in cancer treatment was carried out in the West Bank/ Palestine. A questionnaire was distributed to one hundred and fifty herbalists, traditional healers and rural dwellers. Collected information included the names of plants, the used parts, types of cancers for which these plants were used and also their methods of preparation. To identify the most important species used, Factor of informant’s consensus (Fic), Fidelity level (Fl) and the Use-value (UV) were calculated. Collected data has shown that 72 plants are utilized for treatment of cancer, belonging to 44 families; from them Compositae and Lamiaceae were the most common. Leaves and fruits were the most commonly used parts, while decoctions, infusions and syrups were the main methods of preparation. Lung cancer was the most common type of cancer treated with these plants and Ephedra alata was the most commonly used plant for treatment of cancer in Palestine. The Fic was high for all the plants; Fl was 100 % for many plants, the highest UV (0.72) was for Ephedra alata. This study showed that many herbal remedies are still used by herbalists in Palestine for treatment of cancer; some of them have been approved scientifically while others are not. A combined effort between informants and scientific institutions working in this field can help in the discovery of new anticancer agents. Moreover, scientists must explore the most suitable method of extraction, formulation and dose determination in order to achieve the best benefits from these herbals.

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Ethnopharmacological survey of herbal remedies used for treatment of various types of cancer and their methods of preparations in the West Bank-Palestine.

Cancer is a major disease worldwide, and many patients use complementary and alternative treatments. The purpose of this study was to identify the herbal remedies and functional foods used as complementary medicine by prostate, breast and colorectal cancer patients at speciality care facilities in Trinidad. We also sought to determine how patients rated the efficacy of these modalities compared with conventional treatment. A descriptive, cross-sectional survey was conducted using an interviewer-administered pilot-tested de novo questionnaire during the period June to August 2012 at two speciality treatment centres on the island. Data was analysed using χ2 analyses. Among the 150 patients who reported use of herbal remedies/functional foods, soursop (Annona muricata L.) was the most popular; with 80.7 % using the leaves, bark, fruit and seeds on a regular basis. Other common herbal remedies/functional foods included wheatgrass (Triticum aestivum L.), saffron (Crocus sativus L.) and Aloe vera (L.) Burm. f. The most commonly used functional foods were beetroot (Beta vulgaris L.), carrots (Daucus carata L.) and papaya (Carica papaya L.) used by 43.3 % of patients; and these were mostly blended as a mixture. Herbal remedies and functional foods were used on a daily basis and patients believed that this modality was equally (32.0 %) or more efficacious (14.7 %) than conventional treatment. This survey identified the most common herbal remedies and functional foods used among prostate, breast and colorectal cancer patients in Trinidad. Although functional foods rarely pose a problem, herbs may interact with conventional chemotherapy and physicians need to inform patients regarding probable herb-drug interactions.

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Herbal remedies and functional foods used by cancer patients attending specialty oncology clinics in Trinidad.

Objectives: Identify and highlight research issues and methods used in studying Complementary and Alternative Medicine (CAM) information needs, access, and exchange over the Internet. Methods: A literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines from PubMed to identify articles that have studied Internet use in the CAM context. Additional searches were conducted at Nature.com and Google Scholar. Results: The Internet provides a major medium for attaining CAM information and can also serve as an avenue for conducting CAM related surveys. Based on the literature analyzed in this review, there seems to be significant interest in developing methodologies for identifying CAM treatments, including the analysis of search query data and social media platform discussions. Several studies have also underscored the challenges in developing approaches for identifying the reliability of CAM-related information on the Internet, which may not be supported with reliable sources. The overall findings of this review suggest that there are opportunities for developing approaches for making available accurate information and developing ways to restrict the spread and sale of potentially harmful CAM products and information. Conclusions: Advances in Internet research are yet to be used in context of understanding CAM prevalence and perspectives. Such approaches may provide valuable insights into the current trends and needs in context of CAM use and spread.

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Identifying Complementary and Alternative Medicine Usage Information from Internet Resources. A Systematic Review.

Complementary medicine (CM) use is common among cancer patients. However, little is known about CM products that are utilised during radiotherapy and/or chemotherapy. Out of 62 cancer patients who completed a specialised survey, 35 (56%) consumed some type of CM during active anti-cancer therapy. Cancer patients reported the use of herbal teas (52%), vitamins and other dietary supplements (45%), vegetables and juices (39%), special diets (19%), herbal medicines, including Chinese medicines (19%) and 'immunomodulators' (3%). Most of patients (86%) consumed CM products every day. However, nearly 47% of CM users did not admit this to their oncologists. Majority of CM users (85%) were convinced that supplementary products increase the efficacy of standard anti-cancer therapy and prolong their survival. Information about CM was mainly obtained through internet sources (36%), books and brochures (25%). Although most CM users (82%) trusted the received information, 73% of them admitted that additional information about CM methods would be necessary. Patients would like to receive additional information through a specialised consultation (60%), but also from brochures (44%) and the internet (20%). Adequate counselling of patients is of paramount importance since some CM methods may cause significant side effects and decrease the efficacy of radiotherapy and/or chemotherapy.

R. Pihlak

Papers

Complementary medicine use among cancer patients receiving radiotherapy and chemotherapy: methods, sources of information and the need for counselling