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Traditional and Complementary Medicine in Pediatric Oncology and Low-Middle Income Countries: Recommendations from the International Society of Pediatric Oncology (SIOP), T&CM Collaborative

Traditional and Complementary Medicine in Pediatric Oncology and Low-Middle Income Countries:... Abstract Significant strides have been made in the treatment of childhood cancer. Improvements in survival have led to increased attention toward supportive care indications; including the use of traditional and complementary medicine (T&CM). The use of T&CM among children and adolescents with cancer is well documented in both high-income countries (HICs) and low-middle income countries (LMICs). A higher incidence of the use of T&CM has been reported among children undergoing treatment in LMICs, which has elevated concerns related to drug interactions, adherence to therapy, and treatment-related toxicities. These observations have underscored the need for effective models of integrative care that are culturally sensitive yet sustainable in an LMIC setting. We present considerations inclusive of the clinical care, educational opportunities, governmental policy, and research priorities necessary for the development of models of integrative care for pediatric cancer units in an LMIC setting. Clinical outcomes in childhood cancer have improved considerably in the last few decades, with 80% of children in high-income countries (HICs) now surviving into adulthood (1). Improved survival has led to an increase in educational opportunities and research initiatives in supportive care, which have included the role of traditional and complementary medicine (T&CM). In HICs, T&CM is often a component of comprehensive cancer centers (2–4) and has established a prominent position in many divisions of pediatric oncology, national pediatric research agendas (5), and international research consortia and societies. Collectively, this reflects an emerging conceptual model of care and a shift away from “alternative therapies” to that of “complementary or integrative care.” However, in many low- and middle-income countries (LMICs), where survival of childhood cancer is often lower, there remains a strong divide between conventional medicine and T&CM. The majority of children with cancer undergo treatment in an LMIC (6). Significant improvements in access to well-trained pediatric oncologists, essential medicines, and supportive care have resulted in noteworthy increases in survival (6). However, delays in presentation and abandonment of care to pursue T&CM practices exclusively remain a concern because outcomes are typically poorer for those children (7–11). The World Health Organization (WHO) has advocated for the integration of T&CM into noncommunicable disease management as integration has the potential to improve access to care in low-resource settings, to promote safety, efficacy, and quality, and to support culturally safe practices (12). The UN Declaration on the Rights of Indigenous People affirms this movement by codifying the right to maintain traditional healing practices (13). Within pediatric oncology, an effective infrastructure exists with several well-established regional research consortia such as Asociación de Hemato-Oncología Pediátrica de Centro América (AHOPCA) (14), Indian Pediatric Oncology Group (InPOG) (15), and the International Society of Pediatric Oncology (SIOP) Africa/PODC Collaborative Wilms Tumour Project (16). Importantly, these consortia have all developed an effective structure to conduct clinical trials and facilitate educational agendas and could be leveraged to advance global T&CM policies and strategies (6). In many LMICs, there is a strong history of the use of T&CM, with traditional healers having a recognized role in community health programs (12,17). A systematic review performed by the T&CM Collaborative of the SIOP found that the use of T&CM during childhood cancer care is significantly higher in LMICs compared with HICs, with the median rate of use at 66.7% ± 19% compared with 47.2% ± 20% (P = .02), respectively (18). This may be related to a firm system of beliefs in the therapeutic properties of T&CM. Recent surveys have found that belief in the therapeutic properties of T&CM was stronger among clinicians (19,20) as well as parents (21,22) in LMICs, and belief has been found to be a significant predictor of the use of T&CM in that setting (23). However, the majority of parents taking treatment for childhood cancer in LMICs do not share use of T&CM with physicians due to fear of rejection of T&CM, putting them at risk of potentially hazardous drug interactions and toxicities, necessitating the need for integrative care models (24). Advancing Pediatric Integrative Care Models in LMICs The widespread and ongoing use of T&CM in pediatric oncology prompts the need for global efforts aimed at establishing models of care that are culturally appropriate and evidence-based. Sustainable and accepted models of integrative care with traditional healers are likely to vary widely depending on the context-specific needs, history, and health system. For example, conventional and Traditional Chinese Medicine providers often work closely and openly in China, Singapore, and the Republic of Korea (12,25). In contrast, in Cameroon (8,26) and Canada (27–29), harmonized program building has had to start with building relationships, trust, and mutual respect. In each of these settings, clinical resources, educational opportunities, governmental policies, and research have interfaced synergistically to move toward a functional model of integrative care. Considerations within each of these domains are described in Table 1. Table 1. Domains of institutional T&CM programs* Domain . Evaluative and literal questions . Clinical resources Existing T&CM clinical services—Are T&CM services provided on site or only outside of institution? If on site, how are T&CM services woven into the institutional clinical care model? If off site, how is communication about clinical T&CM services delivered among providers? What are the risks/benefits of the T&CM therapy? What is the quality of evidence for/against a T&CM therapy? Clinical features (diagnosis, treatment regimen, expected toxicities, survival)—Is there a role for a T&CM therapy to further enhance existing clinical care resources? Can T&CM be beneficial in the palliative care setting? Child and family beliefs—What are the family/child’s T&CM beliefs? Are the parents and child in agreement? Burden of T&CM therapy—Are there positive/negative costs or quality of life factors associated with the T&CM therapy? Educational opportunities Are there institutional resources available to support educational opportunities in T&CM for staff? Is there access to internet for web-based educational lectures/meetings? Are there opportunities for bidirectional institutional or regional meetings on T&CM? Are educational materials on T&CM available for parents or staff? Is there an established mechanism for traditional healers and conventional specialists to communicate and learn about development of integrative care plans? Governmental policy Is there a governing body overseeing T&CM? If yes, which therapies within T&CM? What are the regulations governing the production, stability, and purity of dietary or herbal supplements? If none, what are the environmental conditions in which the supplements are being produced? Are there agencies governing licensure of T&CM providers? Is there opportunity to adopt national policies and procedures for institution? Does the institution have an institutional policy on T&CM? Research platform What are the institutional resources for conducting T&CM research? Are there opportunities to learn about research methodology? Are there local, regional, or international entities to support research capacity building? Within an institution, what type of research studies would be beneficial to support integration of T&CM? What are the risks/benefits involved in conducting T&CM research? Domain . Evaluative and literal questions . Clinical resources Existing T&CM clinical services—Are T&CM services provided on site or only outside of institution? If on site, how are T&CM services woven into the institutional clinical care model? If off site, how is communication about clinical T&CM services delivered among providers? What are the risks/benefits of the T&CM therapy? What is the quality of evidence for/against a T&CM therapy? Clinical features (diagnosis, treatment regimen, expected toxicities, survival)—Is there a role for a T&CM therapy to further enhance existing clinical care resources? Can T&CM be beneficial in the palliative care setting? Child and family beliefs—What are the family/child’s T&CM beliefs? Are the parents and child in agreement? Burden of T&CM therapy—Are there positive/negative costs or quality of life factors associated with the T&CM therapy? Educational opportunities Are there institutional resources available to support educational opportunities in T&CM for staff? Is there access to internet for web-based educational lectures/meetings? Are there opportunities for bidirectional institutional or regional meetings on T&CM? Are educational materials on T&CM available for parents or staff? Is there an established mechanism for traditional healers and conventional specialists to communicate and learn about development of integrative care plans? Governmental policy Is there a governing body overseeing T&CM? If yes, which therapies within T&CM? What are the regulations governing the production, stability, and purity of dietary or herbal supplements? If none, what are the environmental conditions in which the supplements are being produced? Are there agencies governing licensure of T&CM providers? Is there opportunity to adopt national policies and procedures for institution? Does the institution have an institutional policy on T&CM? Research platform What are the institutional resources for conducting T&CM research? Are there opportunities to learn about research methodology? Are there local, regional, or international entities to support research capacity building? Within an institution, what type of research studies would be beneficial to support integration of T&CM? What are the risks/benefits involved in conducting T&CM research? * T&CM = traditional and complementary medicine. Table 1. Domains of institutional T&CM programs* Domain . Evaluative and literal questions . Clinical resources Existing T&CM clinical services—Are T&CM services provided on site or only outside of institution? If on site, how are T&CM services woven into the institutional clinical care model? If off site, how is communication about clinical T&CM services delivered among providers? What are the risks/benefits of the T&CM therapy? What is the quality of evidence for/against a T&CM therapy? Clinical features (diagnosis, treatment regimen, expected toxicities, survival)—Is there a role for a T&CM therapy to further enhance existing clinical care resources? Can T&CM be beneficial in the palliative care setting? Child and family beliefs—What are the family/child’s T&CM beliefs? Are the parents and child in agreement? Burden of T&CM therapy—Are there positive/negative costs or quality of life factors associated with the T&CM therapy? Educational opportunities Are there institutional resources available to support educational opportunities in T&CM for staff? Is there access to internet for web-based educational lectures/meetings? Are there opportunities for bidirectional institutional or regional meetings on T&CM? Are educational materials on T&CM available for parents or staff? Is there an established mechanism for traditional healers and conventional specialists to communicate and learn about development of integrative care plans? Governmental policy Is there a governing body overseeing T&CM? If yes, which therapies within T&CM? What are the regulations governing the production, stability, and purity of dietary or herbal supplements? If none, what are the environmental conditions in which the supplements are being produced? Are there agencies governing licensure of T&CM providers? Is there opportunity to adopt national policies and procedures for institution? Does the institution have an institutional policy on T&CM? Research platform What are the institutional resources for conducting T&CM research? Are there opportunities to learn about research methodology? Are there local, regional, or international entities to support research capacity building? Within an institution, what type of research studies would be beneficial to support integration of T&CM? What are the risks/benefits involved in conducting T&CM research? Domain . Evaluative and literal questions . Clinical resources Existing T&CM clinical services—Are T&CM services provided on site or only outside of institution? If on site, how are T&CM services woven into the institutional clinical care model? If off site, how is communication about clinical T&CM services delivered among providers? What are the risks/benefits of the T&CM therapy? What is the quality of evidence for/against a T&CM therapy? Clinical features (diagnosis, treatment regimen, expected toxicities, survival)—Is there a role for a T&CM therapy to further enhance existing clinical care resources? Can T&CM be beneficial in the palliative care setting? Child and family beliefs—What are the family/child’s T&CM beliefs? Are the parents and child in agreement? Burden of T&CM therapy—Are there positive/negative costs or quality of life factors associated with the T&CM therapy? Educational opportunities Are there institutional resources available to support educational opportunities in T&CM for staff? Is there access to internet for web-based educational lectures/meetings? Are there opportunities for bidirectional institutional or regional meetings on T&CM? Are educational materials on T&CM available for parents or staff? Is there an established mechanism for traditional healers and conventional specialists to communicate and learn about development of integrative care plans? Governmental policy Is there a governing body overseeing T&CM? If yes, which therapies within T&CM? What are the regulations governing the production, stability, and purity of dietary or herbal supplements? If none, what are the environmental conditions in which the supplements are being produced? Are there agencies governing licensure of T&CM providers? Is there opportunity to adopt national policies and procedures for institution? Does the institution have an institutional policy on T&CM? Research platform What are the institutional resources for conducting T&CM research? Are there opportunities to learn about research methodology? Are there local, regional, or international entities to support research capacity building? Within an institution, what type of research studies would be beneficial to support integration of T&CM? What are the risks/benefits involved in conducting T&CM research? * T&CM = traditional and complementary medicine. Clinical Resources Determining the safety of a T&CM therapy is difficult because of the wide array of therapies, the lack of data supporting the safety and efficacy, and the fact that Indigenous ways of knowing are not based on the Eurocentric scientific method (26). Similar to conventional cancer therapies, T&CM therapies found to be efficacious in HICs warrant special consideration as their direct application in an LMIC may not be feasible or safe. Other important factors to consider include prognosis, goals of care, duration of proposed therapy, and treatment-related toxicity as these have been shown to be associated with the use of T&CM. Counseling families with a nonjudgmental approach that establishes an open forum to discuss belief systems, concerns, and risks/benefits is an essential first step. T&CM therapies that pose a risk to the child, interfere with or delay the delivery of cancer therapy, or create financial or emotional burden on the family should be discussed in a supportive environment inclusive of all family members and clinicians (T&CM and conventional) involved in the care of the child. Integrative care plans may be established a priori with all participants actively involved in their development and execution to ensure timely delivery of care so that clinical outcomes are not diminished. Educational Opportunities Advancing integrative care in LMICs will necessitate a multifactorial educational approach inclusive of bidirectional initiatives aimed at T&CM providers, conventional medicine clinicians, and families. Educational opportunities may be limited or fervently contested, particularly in parts of the world where traditional health systems and healing methods have existed for thousands of years, such that they are deeply embedded into the history and culture of the region and may have been marginalized or even historically outlawed (26). Collaborating with established entities may bridge this divide. For example, the SIOP T&CM collaborative has increased educational opportunities for all clinicians, clinical investigators, and patient advocacy groups through its annual meetings and web-based meetings through the Cure4Kids platform. Moreover, the society has been successful in India and Africa at engaging traditional healers in attending annual and regional meetings to facilitate bidirectional educational opportunities. Governmental Policy Public health policies governing the safe integration of T&CM in LMICs requires consideration prior to establishing integrative medicine programs. The WHO’s report on T&CM strategy found an increase in the number of member states who have adopted policies overseeing traditional medicine practices and regulation of herbal medicines (12). However, in many member states, this is lacking entirely. In countries where no governing oversight has been established, adhering to standards set forth by cancer centers in HICs may serve as an initial reference model. Several regional models of global integration have also been described that ensure safe, evidence-based integrative models of care (4). Research Platform Clinical and translational research is essential for the successful integration of T&CM into cancer care. One such effective model is the AHOPCA, a Central American research consortium. Annual AHOPCA meetings serve as a platform to discuss research and hold educational symposiums on T&CM. This model has been successful in the identification of local or Indigenous therapies that carry risk, as well as those that may hold promise within supportive care regimens. Although integration will be contingent on the outcomes of clinical trials, the success of AHOPCA in spearheading a regional initiative in T&CM may serve as a global model for integration for other regional consortia (23,30). Conclusion Despite the risks and legitimate concerns associated with T&CM therapies, the global community of pediatric oncology is advancing toward an evidence-based, culturally sensitive model of integrative medicine, even with limited resources. We provide considerations and strategies to resolve the divide between T&CM providers and conventional treatments. Most importantly, our goal is to minimize the risks of integration while also ensuring the delivery of cancer therapy to children. Combined, we are equipped to further improve health outcomes and quality of life for children and adolescents afflicted with cancer around the globe. Funding This work was supported by the Tamarind Foundation (EL), the Mentored Research Scholar Grant (127000-MRSG-14-157-01-CCE), and the American Cancer Society (EL). Note The authors would like to recongize their many collaborators located in low- and middle-income countries; this global effort would not be possible without their dedication to advancing care for children and adolescents with cancer. References 1 National Cancer Institute . SEER Cancer Statistics Review 1975-2009. http://seer.cancer.gov/csr/1975_2009_pops09/index.html. Accessed October 1, 2016. 2 Frenkel M , Cohen L, Peterson N, et al. Integrative medicine consultation service in a comprehensive cancer center: Findings and outcomes . Integr Cancer Ther. 2010 ; 9 3 : 276 – 283 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Deng G. Integrative cancer care in a US academic cancer centre: The Memorial Sloan-Kettering Experience . Curr Oncol. 2008 ; 15(suppl 2) :s108, es68–es71. OpenURL Placeholder Text WorldCat 4 Ben-Arye E , Schiff E, Zollman C, et al. Integrating complementary medicine in supportive cancer care models across four continents . Med Oncol. 2013 ; 30 2 : 511 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Sung L , Zaoutis T, Ullrich NJ, et al. Children's Oncology Group's 2013 blueprint for research: Cancer control and supportive care . Pediatr Blood Cancer. 2013 ; 60 6 : 1027 – 1030 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Rodriguez-Galindo C , Friedrich P, Alcasabas P, et al. Toward the cure of all children with cancer through collaborative efforts: Pediatric oncology as a global challenge . J Clin Oncol. 2015 ; 33 27 : 3065 – 3073 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Mbah G , Kouya F, Hesseling P, et al. Provision of selected knowledge to rural nurses in North west Cameroon: A major contribution towards early diagnosis of childhood cancer. Paper presented at: International Society of Pediatric Oncology, Africa; April 23–25, 2014; Dar es Salaam, Tanzania. 8 Labhardt ND , Aboa SM, Manga E, et al. Bridging the gap: How traditional healers interact with their patients. A comparative study in Cameroon . Trop Med Int Health. 2010 ; 15 9 : 1099 – 1108 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 9 Arora R , Eden T, Pizer B. The problem of treatment abandonment in children from developing countries with cancer . Pediatr Blood Cancer. 2007 ; 49 7 : 941 – 946 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Hesseling P , Ngum E, Kiag M, et al. Burkitt lymphoma in Cameroon: The role of traditional healers - a prospective study in 188 patients . Pediatr Blood Cancer. 2010 ; 55 5 : 869 . OpenURL Placeholder Text WorldCat 11 A. S , Jain V, Yadav S, et al. Move to alternative medicine why? and when? The Indian scenario . Pediatr Blood Cancer. 2005 ; 45 : 578 . OpenURL Placeholder Text WorldCat 12 World Health Organization . WHO traditional medicine strategy 2014-2023. http://www.who.int/medicines/publications/traditional/trm_strategy14_23/en/. Accessed October 1, 2016. 13 United Nations . Declaration on the rights of indigenous peoples. 2008 . http://www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf. Accessed October 1, 2016. 14 Barr RD , Antillon Klussmann F, Baez F, et al. Asociacion de Hemato-Oncologia Pediatrica de Centro America (AHOPCA): A model for sustainable development in pediatric oncology . Pediatr Blood Cancer. 2014 ; 61 2 : 345 – 354 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Arora RS , Bakhshi S. Indian Pediatric Oncology Group (InPOG) – Collaborative research in India comes of age. Pediatr Hematol Oncol J. 2016 ; 1 1 : 13 – 17 . OpenURL Placeholder Text WorldCat 16 Israels T , Kambugu J, Kouya F, et al. Clinical trials to improve childhood cancer care and survival in sub-Saharan Africa . Nat Rev Clin Oncol. 2013 ; 10 10 : 599 – 604 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Shrivastava SR , Shrivastava PS, Ramasamy J. Mainstreaming of ayurveda, yoga, naturopathy, unani, siddha, and homeopathy with the health care delivery system in India . J Tradit Complement Med. 2015 ; 5 2 : 116 – 118 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Diorio C , Lam C, Ladas E, et al. Global use of traditional and complementary medicine in childhood cancer: A systematic review . J Global Oncol. 2016 ; in press. OpenURL Placeholder Text WorldCat 19 Gunawan S , Arnoldussen M, Gordijn MS, et al. Comparing health-care providers' perspectives on complementary and alternative medicine in childhood cancer between Netherlands and Indonesia . Pediatr Blood Cancer. 2016 ; 63 1 : 118 – 123 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Susilawati D , Sitaresmi M, Handayani K, et al. Health care providers' and parents' perspectives on complementary alternative medicine in children with cancer in Indonesia . Asian Pac J Cancer Prev. 2016 ; 17 7 : 3235 – 3242 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 21 Afungchwi G , P. H, C. K, et al. Role of traditional medicine in Burkitt lymphoma diagnosis - necessity for collaboration. Paper presented at: International Society of Pediatric Oncology; October 7, 2012 ; London, England. Abstract S160, p. 62. 22 Njuguna F , Mostert S, Seijffert A, et al. Parental experiences of childhood cancer treatment in Kenya . Support Care Cancer. 2015 ; 23 5 : 1251 – 1259 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Ladas EJ , Lin M, Antillion F, et al. Improving our understanding of the use of traditional complementary/alternative medicine in children with cancer . Cancer. 2015 ; 121 9 : 1492 – 1498 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Ghag S , Achrekar M, Arora BA. A study to explore use of Complementary and Alternative Medicine (CAM) among children diagnosed with cancer in tertiary care cancer hospital . Pediatr Blood Cancer . 2016 ; in press. OpenURL Placeholder Text WorldCat 25 National Bureau of Statistics. Government of China NBoSoC . China Statistical Yearbook 2011:Chinese Medicine (1987-2010). Beijing, China: China Statistics Press; 2011 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 26 Fokunang CN , Ndikum V, Tabi OY, et al. Traditional medicine: Past, present and future research and development prospects and integration in the National Health System of Cameroon . Afr J Tradit Complement Altern Med. 2011 ; 8 3 : 284 – 295 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 27 Cancer Care Ontario . Aboriginal cancer strategy III 2015-2019. http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=345455. Accessed October 1, 2016. 28 Hill D. Traditional medicine in contemporary contexts - protecting and respecting indigenous knowledge and medicine. 2003 . http://www.naho.ca/documents/naho/english/pdf/research_tradition.pdf. Accessed October 1, 2016. 29 Conference report and recommendations . Moving Forward Together: A Conference about Harmonizing Indigenous Wellness in Medicine and Health Practices; November 27-28, 2015; Six Nations, Ontario. http://www.snhs.ca/MovingForwardConferenceReport.pdf. Accessed October 1, 2016. 30 Ladas EJ , Rivas S, Ndao D, et al. Use of traditional and complementary/alternative medicine (TCAM) in children with cancer in Guatemala . Pediatr Blood Cancer. 2014 ; 61 4 : 687 – 692 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JNCI Monographs Oxford University Press

Traditional and Complementary Medicine in Pediatric Oncology and Low-Middle Income Countries: Recommendations from the International Society of Pediatric Oncology (SIOP), T&CM Collaborative

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Oxford University Press
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© The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
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1052-6773
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Abstract

Abstract Significant strides have been made in the treatment of childhood cancer. Improvements in survival have led to increased attention toward supportive care indications; including the use of traditional and complementary medicine (T&CM). The use of T&CM among children and adolescents with cancer is well documented in both high-income countries (HICs) and low-middle income countries (LMICs). A higher incidence of the use of T&CM has been reported among children undergoing treatment in LMICs, which has elevated concerns related to drug interactions, adherence to therapy, and treatment-related toxicities. These observations have underscored the need for effective models of integrative care that are culturally sensitive yet sustainable in an LMIC setting. We present considerations inclusive of the clinical care, educational opportunities, governmental policy, and research priorities necessary for the development of models of integrative care for pediatric cancer units in an LMIC setting. Clinical outcomes in childhood cancer have improved considerably in the last few decades, with 80% of children in high-income countries (HICs) now surviving into adulthood (1). Improved survival has led to an increase in educational opportunities and research initiatives in supportive care, which have included the role of traditional and complementary medicine (T&CM). In HICs, T&CM is often a component of comprehensive cancer centers (2–4) and has established a prominent position in many divisions of pediatric oncology, national pediatric research agendas (5), and international research consortia and societies. Collectively, this reflects an emerging conceptual model of care and a shift away from “alternative therapies” to that of “complementary or integrative care.” However, in many low- and middle-income countries (LMICs), where survival of childhood cancer is often lower, there remains a strong divide between conventional medicine and T&CM. The majority of children with cancer undergo treatment in an LMIC (6). Significant improvements in access to well-trained pediatric oncologists, essential medicines, and supportive care have resulted in noteworthy increases in survival (6). However, delays in presentation and abandonment of care to pursue T&CM practices exclusively remain a concern because outcomes are typically poorer for those children (7–11). The World Health Organization (WHO) has advocated for the integration of T&CM into noncommunicable disease management as integration has the potential to improve access to care in low-resource settings, to promote safety, efficacy, and quality, and to support culturally safe practices (12). The UN Declaration on the Rights of Indigenous People affirms this movement by codifying the right to maintain traditional healing practices (13). Within pediatric oncology, an effective infrastructure exists with several well-established regional research consortia such as Asociación de Hemato-Oncología Pediátrica de Centro América (AHOPCA) (14), Indian Pediatric Oncology Group (InPOG) (15), and the International Society of Pediatric Oncology (SIOP) Africa/PODC Collaborative Wilms Tumour Project (16). Importantly, these consortia have all developed an effective structure to conduct clinical trials and facilitate educational agendas and could be leveraged to advance global T&CM policies and strategies (6). In many LMICs, there is a strong history of the use of T&CM, with traditional healers having a recognized role in community health programs (12,17). A systematic review performed by the T&CM Collaborative of the SIOP found that the use of T&CM during childhood cancer care is significantly higher in LMICs compared with HICs, with the median rate of use at 66.7% ± 19% compared with 47.2% ± 20% (P = .02), respectively (18). This may be related to a firm system of beliefs in the therapeutic properties of T&CM. Recent surveys have found that belief in the therapeutic properties of T&CM was stronger among clinicians (19,20) as well as parents (21,22) in LMICs, and belief has been found to be a significant predictor of the use of T&CM in that setting (23). However, the majority of parents taking treatment for childhood cancer in LMICs do not share use of T&CM with physicians due to fear of rejection of T&CM, putting them at risk of potentially hazardous drug interactions and toxicities, necessitating the need for integrative care models (24). Advancing Pediatric Integrative Care Models in LMICs The widespread and ongoing use of T&CM in pediatric oncology prompts the need for global efforts aimed at establishing models of care that are culturally appropriate and evidence-based. Sustainable and accepted models of integrative care with traditional healers are likely to vary widely depending on the context-specific needs, history, and health system. For example, conventional and Traditional Chinese Medicine providers often work closely and openly in China, Singapore, and the Republic of Korea (12,25). In contrast, in Cameroon (8,26) and Canada (27–29), harmonized program building has had to start with building relationships, trust, and mutual respect. In each of these settings, clinical resources, educational opportunities, governmental policies, and research have interfaced synergistically to move toward a functional model of integrative care. Considerations within each of these domains are described in Table 1. Table 1. Domains of institutional T&CM programs* Domain . Evaluative and literal questions . Clinical resources Existing T&CM clinical services—Are T&CM services provided on site or only outside of institution? If on site, how are T&CM services woven into the institutional clinical care model? If off site, how is communication about clinical T&CM services delivered among providers? What are the risks/benefits of the T&CM therapy? What is the quality of evidence for/against a T&CM therapy? Clinical features (diagnosis, treatment regimen, expected toxicities, survival)—Is there a role for a T&CM therapy to further enhance existing clinical care resources? Can T&CM be beneficial in the palliative care setting? Child and family beliefs—What are the family/child’s T&CM beliefs? Are the parents and child in agreement? Burden of T&CM therapy—Are there positive/negative costs or quality of life factors associated with the T&CM therapy? Educational opportunities Are there institutional resources available to support educational opportunities in T&CM for staff? Is there access to internet for web-based educational lectures/meetings? Are there opportunities for bidirectional institutional or regional meetings on T&CM? Are educational materials on T&CM available for parents or staff? Is there an established mechanism for traditional healers and conventional specialists to communicate and learn about development of integrative care plans? Governmental policy Is there a governing body overseeing T&CM? If yes, which therapies within T&CM? What are the regulations governing the production, stability, and purity of dietary or herbal supplements? If none, what are the environmental conditions in which the supplements are being produced? Are there agencies governing licensure of T&CM providers? Is there opportunity to adopt national policies and procedures for institution? Does the institution have an institutional policy on T&CM? Research platform What are the institutional resources for conducting T&CM research? Are there opportunities to learn about research methodology? Are there local, regional, or international entities to support research capacity building? Within an institution, what type of research studies would be beneficial to support integration of T&CM? What are the risks/benefits involved in conducting T&CM research? Domain . Evaluative and literal questions . Clinical resources Existing T&CM clinical services—Are T&CM services provided on site or only outside of institution? If on site, how are T&CM services woven into the institutional clinical care model? If off site, how is communication about clinical T&CM services delivered among providers? What are the risks/benefits of the T&CM therapy? What is the quality of evidence for/against a T&CM therapy? Clinical features (diagnosis, treatment regimen, expected toxicities, survival)—Is there a role for a T&CM therapy to further enhance existing clinical care resources? Can T&CM be beneficial in the palliative care setting? Child and family beliefs—What are the family/child’s T&CM beliefs? Are the parents and child in agreement? Burden of T&CM therapy—Are there positive/negative costs or quality of life factors associated with the T&CM therapy? Educational opportunities Are there institutional resources available to support educational opportunities in T&CM for staff? Is there access to internet for web-based educational lectures/meetings? Are there opportunities for bidirectional institutional or regional meetings on T&CM? Are educational materials on T&CM available for parents or staff? Is there an established mechanism for traditional healers and conventional specialists to communicate and learn about development of integrative care plans? Governmental policy Is there a governing body overseeing T&CM? If yes, which therapies within T&CM? What are the regulations governing the production, stability, and purity of dietary or herbal supplements? If none, what are the environmental conditions in which the supplements are being produced? Are there agencies governing licensure of T&CM providers? Is there opportunity to adopt national policies and procedures for institution? Does the institution have an institutional policy on T&CM? Research platform What are the institutional resources for conducting T&CM research? Are there opportunities to learn about research methodology? Are there local, regional, or international entities to support research capacity building? Within an institution, what type of research studies would be beneficial to support integration of T&CM? What are the risks/benefits involved in conducting T&CM research? * T&CM = traditional and complementary medicine. Table 1. Domains of institutional T&CM programs* Domain . Evaluative and literal questions . Clinical resources Existing T&CM clinical services—Are T&CM services provided on site or only outside of institution? If on site, how are T&CM services woven into the institutional clinical care model? If off site, how is communication about clinical T&CM services delivered among providers? What are the risks/benefits of the T&CM therapy? What is the quality of evidence for/against a T&CM therapy? Clinical features (diagnosis, treatment regimen, expected toxicities, survival)—Is there a role for a T&CM therapy to further enhance existing clinical care resources? Can T&CM be beneficial in the palliative care setting? Child and family beliefs—What are the family/child’s T&CM beliefs? Are the parents and child in agreement? Burden of T&CM therapy—Are there positive/negative costs or quality of life factors associated with the T&CM therapy? Educational opportunities Are there institutional resources available to support educational opportunities in T&CM for staff? Is there access to internet for web-based educational lectures/meetings? Are there opportunities for bidirectional institutional or regional meetings on T&CM? Are educational materials on T&CM available for parents or staff? Is there an established mechanism for traditional healers and conventional specialists to communicate and learn about development of integrative care plans? Governmental policy Is there a governing body overseeing T&CM? If yes, which therapies within T&CM? What are the regulations governing the production, stability, and purity of dietary or herbal supplements? If none, what are the environmental conditions in which the supplements are being produced? Are there agencies governing licensure of T&CM providers? Is there opportunity to adopt national policies and procedures for institution? Does the institution have an institutional policy on T&CM? Research platform What are the institutional resources for conducting T&CM research? Are there opportunities to learn about research methodology? Are there local, regional, or international entities to support research capacity building? Within an institution, what type of research studies would be beneficial to support integration of T&CM? What are the risks/benefits involved in conducting T&CM research? Domain . Evaluative and literal questions . Clinical resources Existing T&CM clinical services—Are T&CM services provided on site or only outside of institution? If on site, how are T&CM services woven into the institutional clinical care model? If off site, how is communication about clinical T&CM services delivered among providers? What are the risks/benefits of the T&CM therapy? What is the quality of evidence for/against a T&CM therapy? Clinical features (diagnosis, treatment regimen, expected toxicities, survival)—Is there a role for a T&CM therapy to further enhance existing clinical care resources? Can T&CM be beneficial in the palliative care setting? Child and family beliefs—What are the family/child’s T&CM beliefs? Are the parents and child in agreement? Burden of T&CM therapy—Are there positive/negative costs or quality of life factors associated with the T&CM therapy? Educational opportunities Are there institutional resources available to support educational opportunities in T&CM for staff? Is there access to internet for web-based educational lectures/meetings? Are there opportunities for bidirectional institutional or regional meetings on T&CM? Are educational materials on T&CM available for parents or staff? Is there an established mechanism for traditional healers and conventional specialists to communicate and learn about development of integrative care plans? Governmental policy Is there a governing body overseeing T&CM? If yes, which therapies within T&CM? What are the regulations governing the production, stability, and purity of dietary or herbal supplements? If none, what are the environmental conditions in which the supplements are being produced? Are there agencies governing licensure of T&CM providers? Is there opportunity to adopt national policies and procedures for institution? Does the institution have an institutional policy on T&CM? Research platform What are the institutional resources for conducting T&CM research? Are there opportunities to learn about research methodology? Are there local, regional, or international entities to support research capacity building? Within an institution, what type of research studies would be beneficial to support integration of T&CM? What are the risks/benefits involved in conducting T&CM research? * T&CM = traditional and complementary medicine. Clinical Resources Determining the safety of a T&CM therapy is difficult because of the wide array of therapies, the lack of data supporting the safety and efficacy, and the fact that Indigenous ways of knowing are not based on the Eurocentric scientific method (26). Similar to conventional cancer therapies, T&CM therapies found to be efficacious in HICs warrant special consideration as their direct application in an LMIC may not be feasible or safe. Other important factors to consider include prognosis, goals of care, duration of proposed therapy, and treatment-related toxicity as these have been shown to be associated with the use of T&CM. Counseling families with a nonjudgmental approach that establishes an open forum to discuss belief systems, concerns, and risks/benefits is an essential first step. T&CM therapies that pose a risk to the child, interfere with or delay the delivery of cancer therapy, or create financial or emotional burden on the family should be discussed in a supportive environment inclusive of all family members and clinicians (T&CM and conventional) involved in the care of the child. Integrative care plans may be established a priori with all participants actively involved in their development and execution to ensure timely delivery of care so that clinical outcomes are not diminished. Educational Opportunities Advancing integrative care in LMICs will necessitate a multifactorial educational approach inclusive of bidirectional initiatives aimed at T&CM providers, conventional medicine clinicians, and families. Educational opportunities may be limited or fervently contested, particularly in parts of the world where traditional health systems and healing methods have existed for thousands of years, such that they are deeply embedded into the history and culture of the region and may have been marginalized or even historically outlawed (26). Collaborating with established entities may bridge this divide. For example, the SIOP T&CM collaborative has increased educational opportunities for all clinicians, clinical investigators, and patient advocacy groups through its annual meetings and web-based meetings through the Cure4Kids platform. Moreover, the society has been successful in India and Africa at engaging traditional healers in attending annual and regional meetings to facilitate bidirectional educational opportunities. Governmental Policy Public health policies governing the safe integration of T&CM in LMICs requires consideration prior to establishing integrative medicine programs. The WHO’s report on T&CM strategy found an increase in the number of member states who have adopted policies overseeing traditional medicine practices and regulation of herbal medicines (12). However, in many member states, this is lacking entirely. In countries where no governing oversight has been established, adhering to standards set forth by cancer centers in HICs may serve as an initial reference model. Several regional models of global integration have also been described that ensure safe, evidence-based integrative models of care (4). Research Platform Clinical and translational research is essential for the successful integration of T&CM into cancer care. One such effective model is the AHOPCA, a Central American research consortium. Annual AHOPCA meetings serve as a platform to discuss research and hold educational symposiums on T&CM. This model has been successful in the identification of local or Indigenous therapies that carry risk, as well as those that may hold promise within supportive care regimens. Although integration will be contingent on the outcomes of clinical trials, the success of AHOPCA in spearheading a regional initiative in T&CM may serve as a global model for integration for other regional consortia (23,30). Conclusion Despite the risks and legitimate concerns associated with T&CM therapies, the global community of pediatric oncology is advancing toward an evidence-based, culturally sensitive model of integrative medicine, even with limited resources. 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JNCI MonographsOxford University Press

Published: Nov 1, 2017

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