A systematic review of integrative oncology programs

Cancer patients worldwide are increasingly combining complementary health care interventions such as acupuncture, massage therapy, and naturopathic medicine with conventional treatments such as chemotherapy, radiation, and surgery. Population-based studies suggest that at least half of all cancer patients use some type of complementary therapy during their experience with cancer1–5. In parallel with and as a response to that trend, the field of integrative oncology has emerged to ensure that patients have access to evidence-based cancer care that is safe, comprehensive, and patient-centred throughout the cancer spectrum. The goals of integrative oncology are to reduce the side effects of conventional treatment, to improve cancer symptoms, to enhance emotional health, to improve quality of life, and sometimes to enhance the effect of conventional treatments6–8. Sagar and Leis describe integrative oncology as both a science and a philosophy that recognizes the complexity of care for cancer patients and that provides a multitude of evidence-based approaches to accompany conventional therapies and to facilitate health9. In 2009, the Society for Integrative Oncology published practice guidelines, representing evidencebased recommendations for the treatment of common ABSTRACT


INTRODUCTION
Cancer patients worldwide are increasingly combining complementary health care interventions such as acupuncture, massage therapy, and naturopathic medicine with conventional treatments such as chemotherapy, radiation, and surgery.Population-based studies suggest that at least half of all cancer patients use some type of complementary therapy during their experience with cancer [1][2][3][4][5] .In parallel with and as a response to that trend, the field of integrative oncology has emerged to ensure that patients have access to evidence-based cancer care that is safe, comprehensive, and patient-centred throughout the cancer spectrum.
The goals of integrative oncology are to reduce the side effects of conventional treatment, to improve cancer symptoms, to enhance emotional health, to improve quality of life, and sometimes to enhance the effect of conventional treatments [6][7][8] .Sagar and Leis describe integrative oncology as both a science and a philosophy that recognizes the complexity of care for cancer patients and that provides a multitude of evidence-based approaches to accompany conventional therapies and to facilitate health 9 .
In 2009, the Society for Integrative Oncology published practice guidelines, representing evidencebased recommendations for the treatment of common problems encountered by cancer patients 6 .The guidelines are based on a summary and critical analysis of manuscripts and textbook chapters on complementary and integrative medicine in oncology and have proved useful for health professionals in providing evidencebased and patient-centred advice to individual patients.Practice guidelines are, however, only one part of integrative oncology practice.Integrative practice also requires that a number of interdisciplinary professionals practice alongside each other and, ideally, communicate in nonhierarchical and respectful ways to further the goals of treating the whole person and of promoting health 10 .This description of integrative practice is an idealized one, and it is more likely that practice models evolve with integration as a goal that is not necessarily achieved.Although it seems reasonable to expect that all integrative oncology practitioners share a common philosophy of patientcentred, whole-person, and evidence-based care, it is unclear how such a philosophy has developed within real-world examples of integrative oncology programs.The literature contains many reports that document examples of integrative oncology practice, and yet that literature has not been reviewed and summarized.
In the same way that practice guidelines have helped to advance the practice of integrative oncology, a summary of the literature describing integrative oncology programs is needed to inform the development of integrative oncology policies, to further develop and refine existing and new programs of care, and to begin conceptualizing the broader infrastructure of integrative oncology practice, education, and research.
Our objective was to use the methods of systematic review to summarize the research literature describing integrative oncology programs.Specifically, we were interested in summarizing elements relevant to the development and operation of an integrative oncology program or centre, including the components of care, administrative structure, process of care, and measurable outcomes used.

METHODS
We conducted a systematic review of the literature describing integrative oncology programs and centres.We expected a wide range of practice models 11 , and we therefore did not impose a strict definition of integrative health care.Instead, we searched for articles that described examples of integrative oncology care, based on the provision of complementary care in addition to (and not in opposition to) conventional care.Despite setting broad inclusion criteria for integrative oncology programs, we were careful to distinguish between "complementary" and "alternative" care, reviewing only program descriptions that include complementary therapies in addition to "conventional" care provided by medical doctors, including chemotherapy, radiation therapy, and surgery.Complementary therapies represent a diverse set of therapies that are nonsurgical and non-pharmaceutical, but that have known efficacy 6 .Alternative therapies do not have a scientific foundation and are typically promoted as alternatives to conventional care.Given the requirement for evidence within integrative oncology 6,9 , programs that provide alternative care were excluded from our review.
The search incorporated a number of methods to identify published articles.We searched the Allied and Complementary Medicine Database, Cochrane Library, Cochrane Central Register of Controlled Trials, embase, healthstar, medline, premedline, psycinfo, and csa Sociological Abstracts from inception through March 2010.The search strategy for medline appears in Appendix A. We hand-searched eight journals from their inception through December 2010 [ Two investigators independently screened all identified titles and abstracts for potential inclusion in the review.Full-text reports of the selected records from the screening phase were obtained and a final assessment for inclusion was made independently by the same two reviewers.To be included, articles had to describe examples of clinics or programs that provide some combination of complementary and conventional cancer care exclusively to any one or a combination of cancer patients, cancer survivors, or people wishing to prevent cancer.Articles documenting general integrative medicine programs, even if cancer patients made up a substantial portion of the client base, and programs that provide only singleagent complementary therapies were excluded.Further, articles had to document original research or describe the process of cancer care.Abstracts for which we could not locate a full-text article were excluded, as were publications in a language other than English, French, or German.Disagreements were resolved by consensus.
Data were extracted according to 6 main concepts and within 88 data elements guided by the key concepts of integrative health care practice as A standardized data extraction form and guidelines were developed and pilot-tested to enhance reliability in data extraction.All data were extracted by one, and verified by a second, investigator.We contacted authors of the included articles to review key elements of the extracted data related to their programs and to supply any missing data.Data were summarized descriptively, using frequencies for categorical data and content analysis for qualitative data 12 , to generate a list of common categories.
This study was funded by the Lotte and John Hecht Memorial Foundation.The funder had no role in the collection, analysis, or interpretation of data and has no right to approve or disapprove publication of a finished manuscript.Because this study did not involve human participants, ethics approval was not required.

RESULTS
We identified 1622 records for screening, and we reviewed 220 full-text manuscripts for potential inclusion.In total, 53 articles describing 29 examples of integrative oncology programs were included in the review (Figure 1).As part of the identification of eligible programs, we sent e-mail messages to 24 individuals affiliated with the programs or centres included in our review for whom we could locate contact information.We asked those individuals to verify the extracted data and to provide missing data.Messages to 5 recipients were undeliverable, and the 19 remaining messages attracted 11 responses.As a result of this process, two programs were excluded as they were clarified to be integrative medicine and not specifically integrative oncology programs.

Description of Integrative Oncology Programs
Of the 29 integrative oncology programs included in the review, 12  In 14 programs (48%), treatment is offered to people with any type and any stage of cancer; 2 programs (7%) focus solely on breast cancer (clientele type nr = 13, 45%).Patient access to the programs most commonly comes from self-referral by patients (n = 16, 55%); referrals from conventional health care providers (n = 11, 38%), word of mouth (n = 10, 34%), advertising (n = 8, 28%), and referrals from a cancer agency (n = 8, 28%) also account for access.
Few data about the physical characteristics of most centres were reported (physical characteristics nr = 20, 69%), but among the 9 programs that reported some aspect of their physical space, that space was most commonly described using such words as "peaceful," "soothing," and "natural."Some features described included natural elements of wood and water, natural lighting, flowers and gardens, or aromatherapy and relaxing music.

Components of Care
Fewer than half the programs (n = 12, 41%) provide both complementary and conventional therapies in the same location.Of the remaining programs, 8 (28%) provide complementary therapies at one location and collaborate with conventional oncology centres in other settings to provide an integrative approach to care (therapy locations nr = 9, 31% a number of complementary therapies, with mind-body medicine (including meditation, visualization, and relaxation), massage, nutrition counselling, and acupuncture being the most common (Figure 2).The decision to offer specific complementary therapies is most commonly made based on evidence (n = 12, 41%) and patient demand (n = 10, 34%).Other reasons include clinical experience (n = 3, 10%), recommendation from a conventional health care practitioner (n = 2, 7%), recommendation from a complementary health care practitioner (n = 1, 3%), availability of practitioners (n = 1, 3%), and the ability to easily integrate a therapy into a hospital setting (n = 1, 3%).The stated goals of all the included integrative oncology programs were closely aligned, collectively identifying common principles within the field, such as "whole-person," "patient-centred," "collaborative," "empowerment," and "evidencebased."Further, each of the included programs had framed their goals in terms of providing high-quality supportive care alongside, and not in place of, conventional care.
Of the included programs, 12 (41%) reported that practitioners regularly meet in a formal setting; 5 (17%) reported not meeting formally; and 12 (41%) did not report on this topic.Of the 12 programs that reported regular meetings, those meetings occur at least weekly to discuss individual or complex cases, to develop and coordinate integrative care plans, or to provide updates on patients previously discussed.In 9 of the 12 programs, complementary and conventional care providers both attend the meetings; in 3 programs, only the conventional practitioners attend.About half the programs (n = 16, 55%) reported involving family members or caregivers in their integrative program; the remaining 13 programs (45%) reported no data for such involvement.Most programs that involve family members and caregivers offer a package of care to those individuals that is the same as the package offered to patients (n = 8, 28%); others offer support sessions and psychological interventions (n = 3, 10%) or a more limited set of therapies (n = 3, 10%).
Education is often seen as an important component of integrative care, with more than half the programs (n = 16, 55%) reporting that they offer some element of community outreach or education, most commonly seminars or lectures (n = 9, 31%) or curriculum for health professionals (n = 3, 10%).One program described taking advantage of new media technologies, regularly developing and posting blogs and other multimedia entries on their Web site.
In general, few data about the components of integrative care were reported (Figure 3), including whether a primary caregiver is assigned to each patient (nr = 17, 59%), whether patient charts are shared between members of the integrative care team (nr = 16, 55%), and whether practitioners are required to hold certain credentials or to meet certain standards (nr = 18, 62%) or to undergo training specific to cancer (nr = 12, 41%).

Administrative Structure
Although information was scarcely reported for many data elements related to the organizational structure of integrative oncology programs (Figure 3), some elements were fairly well reported.For example, almost two thirds of the programs (n = 18, 62%) reported having dedicated staff, but little information was reported about the number of full-and part-time staff, job titles, and responsibilities.It is also clear that approaching two thirds of the programs (n = 17, 59%) maintained a hospital affiliation, with those programs operating within or beside hospitals or cancer centres, or serving as a community affiliate of a local hospital.
About half the programs (n = 15, 52%) reported some information about the process they followed to develop their organizational structure (process nr = 14, 48%).Strategies varied and seemed to depend on the local environment in which the program would operate and also on the people who were leading the process.Most commonly, a steering committee or subcommittees (or both) were developed to explore issues such as staffing, funding, practice scope, and credentials (n = 5, 17%).Pilot studies and needs assessments were likewise common (n = 5, 17%).Other strategies included consultations with health care professionals, cancer patients, and administrative personnel (n = 3, 10%); offers of complementary or integrative medicine education to health care professionals and cancer patients (n = 3, 10%); and coordinated visits to established integrative oncology programs (n = 1, 3%).
Overall, funding mechanisms show variability and variety, but some within-country similarities are notable.The programs in our sample that operate in England are financed partly through charitable donations and public (National Health Service) or hospital funds, with some volunteer support.Those programs exclusively provide complementary therapies free of charge, sometimes with a donation request and a limit placed on the number of hours or sessions that clients can access.Programs within the United States also rely on support from foundations, private donors, and (in 1 case) research grants, but financing is also assisted through hospital budgets (where relevant), third-party billing, and direct billing to patients.Those programs most commonly recover costs from private insurance plans and direct patient payment, but most also provide at least some therapies free of charge or at a reduced rate.

Process of Care
Information about the initial patient assessment procedure was reported for 20 programs (69%).Initial assessments commonly involve a structured consultation or consultations with one or more therapists to collaboratively develop a care plan (n = 6, 21%); patient education and advice (n = 5, 17%); a structured introduction to available services (n = 4, 14%); a holistic (that is, some combination of physical, psychological, social, or spiritual) assessment (n = 4, 14%); a medical history and a history of complementary and conventional therapy use (n = 3, 10%); an assessment of patient needs, concerns, and expectations (n = 3, 10%); and other assessments such as physical exams, psychological assessments, and lifestyle consultations.Further, three quarters of the programs (n = 21, 72%) reported some details about patient flow through the integrative programs (n = 8, 28%), although the level of detail reported varied widely between programs.The integrative oncology programs included in our review used a variety of elements: tours, orientations, or structured introductory sessions before the start of care; individualized diet or supplementation programs or advice; telephone help lines; routine patient evaluation and follow-up consultations; referral to community-based resources; various means of internal referrals; and patient education, among others.Some programs are inpatient-only programs, others are outpatient-only, and some serve both inpatients and outpatients.Programs also vary by the level of patient involvement in their own care and decision-making, with a tendency toward collaborative decision-making between therapists, patients, and their families.Some programs are very structured, with a common process outlined for each participant or client within the program, and others are very unstructured and rely on patients to identify and schedule appointments for their therapies of choice.Some programs require a written referral or clearance from conventional practitioners to proceed with complementary treatment, and others rely on only informal communication between complementary and conventional cancer professionals, often initiated by patients.
Clearly, the complexity of, and the variety within, programs cannot be summarized succinctly, and so London, U.K.

Hospital-based
Means for practitioner collaboration: Multidisciplinary handover and team meetings.Shared patient charts.
Day-to-day funding and operations: Charitable donations and some government funding.
Complementary therapy cost recovery: All therapies are free of charge.
Research program description: Clinical trials.

Hospital-based
Day-to-day funding and operations: Support from foundations and private donors.
Complementary therapy cost recovery: Most services are provided free of charge.There is a charge for acupuncture, energy-based therapies, massage therapy, and psychotherapy.
Name not provided 63 U.K.

Hospital-based
Day-to-day funding and operations: Charitable donations and government funding.
Complementary therapy cost recovery: All therapies are free of charge.
Name not provided 64 Southeast England, U.K.

Hospital-based
Day-to-day funding and operations: Charitable donations.
Complementary therapy cost recovery: Free of charge with request for discretionary donation after 4 sessions of any therapy.Acupuncture and counseling are always free.

Research program description:
No active research program.A multidisciplinary team reviews information from initial assessment, and treatment options are determined.The team communicates options with primary physician who asked for the consultation.An integrative medicine physician discusses positive and negative aspects of each complementary and integrative option with the patient and the patient chooses treatment options to pursue.Follow up visit after 6-12 weeks to review progress.
Family members are involved in the initial consultation, along with the patient and other significant caregivers.

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Current OnCOlOgy-VOlume There are two ways to access the service.Local people can drop in for an hour-long session of therapies of their choice.For outpatients, there is an introduction at the beginning and a review at the end.Otherwise, there is a 3-or 5-day residential experience.The day and residential courses may be taken individually or in sequence, depending on the needs of the individual.There is also telephone counselling and a doctor phone-in time for those in acute need.
There is a 1-day course "Living Well With and Beyond Cancer," which offers an introduction to the basic principles and practice of the holistic approach used at the Centre.
All programs are open to caregivers.

Rossendale Hospice
After referral (by a health care professional, family member, friend, or patient), a nurse contacts the patient by telephone within 48 hours and information about service is provided.
If the patient chooses to attend, every effort is made to accommodate him or her on the 2 days designated to the service.Therapeutic Touch program at the BC Cancer Agency The supervising counsellor conducts a pretreatment assessment with each patient to determine their cognitive understanding and comfort with the purposes of therapeutic touch, their medical diagnosis, and their suitability for treatment.
Sessions are booked for 30-45 minutes, with 4-6 patients treated at the same time.Each clinic begins with a centering meditation for the practitioners.The volunteers perform an initial hands-on assessment of the energy field around a patient's clothed body and then proceed with the treatment.A check-in for feedback is held at the end of the treatment, and a debriefing session for the volunteers by counsellors occurs at the end of each clinic.
Program available only to cancer patients.not conducting program evaluations, and 11 (38%) were silent on that issue.A range of outcomes are assessed across the programs, including quality of life, cancer-and cancer treatment-related symptoms, well-being, survival, patient-identified concerns and benefits, and descriptions of patient experiences within the program.Some programs rely on researcher-developed questionnaires to assess patient outcomes; others rely on standardized measures.Most commonly, a baseline assessment is made when a patient is first referred to the program, with follow-up occurring after treatment or after a predetermined amount of time.
For evaluation purposes, 3 programs (10%) reported collecting data other than patient outcome data, including clinic volume, therapies used, reasons for referral, financial assistance requests, and client feedback on aspects of the program they liked or would like to see changed.Results of the evaluation programs are used to improve the treatment approach or to develop a case for expansion of the program; they are sometimes published in academic journals or presented at scientific conferences.

DISCUSSION
Our review highlights the internationally growing number and diversity of integrative oncology programs that share a common vision to provide whole-person and patient-centred care, inclusive of evidence-based complementary and conventional medicine.At least 29 such programs are operating internationally, with the 1960s marking the beginnings of such programs and with most having been established since the 1990s.More programs are certainly in operation than are included in our review, given that we reviewed only the English, French, and German academic literature and searched only English-language databases and journals.Most of the programs included in our review are based in England or the United States, which likely does not reflect the actual pattern of integrative oncology programs internationally.For example, in Germany, complementary approaches to cancer care have historically been fairly well integrated with conventional care, although our review captured only 2 German programs.We are also aware of several integrative medicine programs within the United States that include a large cancer focus, but that are not specifically integrative oncology programs, including the Program in Integrative Medicine at the University of Arizona 65 , the University of California at San Francisco Osher Center for Integrative Medicine 66 , the Johns Hopkins Complementary and Integrative Medicine Service 67 , and the Mayo Complementary and Integrative Medicine Program 68 .There are certainly several more examples of integrative oncology programs than were included in our review, indicating that integrative oncology programs are even more varied than described here.At least part of the observed variety across integrative oncology programs can be explained by differences in the political, social, and organizational environments in which they were developed; other factors are the varied backgrounds, skills, and experiences of the leaders driving program development 69,70 .The varied environments have resulted in a wide range of approaches to development and operation, collaboration, communication, and cost recovery.Most definitions of integrative oncology found in the literature refer to a novel and idealized form of health care practice that focuses on the whole person and that includes a new structure and new processes for shared patient management, shared care, and shared overall values and goals 10,11,43 .However, although the programs included in our review clearly strive to achieve that vision, most fall short of implementing the full spectrum of structures and processes expected within truly integrative practices.For example, fewer than half the programs we reviewed reported holding regular inter-professional team meetings or sharing charts with the interprofessional team, processes that are both fundamental to providing seamless, interdisciplinary care inclusive of both conventional and complementary medicine.This lack of agreement between idealized and real-world practice should not, however, reflect poorly on the real-world examples that we reviewed; instead, it reflects the context-dependent nature of those programs 70 .The included integrative oncology programs are quite likely representations of what is possible in the current political, social, and organizational environment in which complementary medicine remains on the margins of mainstream care.Regardless, the observed differences between idealized and real-world practice does raise a question: Just how "integrative" is the discipline of integrative oncology at present?Perhaps our findings signal a need to develop a scale or other tool to help gauge progress towards the vision.Further, the observed variety in operational models highlights the need for all programs-developing and existing-to maintain a comprehensive understanding of factors that could influence sustainability: for example policies, regulations, technology, and patient demands.Through regular process evaluations, integrative oncology programs can adapt to remain relevant and effective in the community they serve 69 .
The articles included in this review are only snapshots of programs at certain points in time, and therefore our review of them does not capture the complexity and fluidity of programs as they adapt and change within their environment.Similarly, we are tied to a reported view of included programs, a view that is inherently limited by the space constraints of the written record and that holds the potential for selective or idealized reporting.To enhance data reliability and to minimize missing data, we attempted to contact personnel within each of the included programs.We were somewhat successful, but we were not able to talk to a representative from every program.It is therefore likely that some of the information reported here is out of date or otherwise no longer applicable.For example, we are aware that at least 1 of the included programs, the Geffen Cancer Center and Research Institute, no longer operates in the reported format.The same could also be true for other programs.

CONCLUSIONS
Our review suggests that distinct integrative oncology models are operating within England and the United States, with few published examples from other countries to be able to draw reliable comparisons.A mixture of both hospital-and communitybased programs operate in each country, but the way in which the day-to-day operations are financed, the programs are administered, and costs are recovered from clients vary.Programs in England are exclusively funded through charitable donations and public or hospital funds, with some volunteer support; programs in the United States sometimes use such sources and additionally obtain support through third-party billing, direct billing to patients, and research grants.Further, programs in England exclusively provide care free of charge, but most place a limit on services that clients can receive.Within the United States, free care is not uncommon, but payment is usually involved, which might be recovered through insurance or direct patient payment.
Given the growth and innovation in the integrative oncology field, we hope that this review provides a starting point to navigate some of the issues involved in developing and establishing such programs.It should be instructive for practitioners, researchers, administrators, and funders working in an integrative oncology environment to read of the varied examples and factors that influence program development.Integrative oncology attempts to bridge numerous therapeutic modalities and philosophies of care, and related programs may therefore not be supported by all types of practitioners despite being requested by many patients.Furthermore, implementation is complicated by a need for system-and cultural-level changes and lack of a universal definition.Ultimately, implementation requires local collaboration and strong and committed leadership to be successful.If people working in these environments continue to publish descriptions of their experiences with program development and operation, including evaluations of the process and outcomes of their programs, the field can continue to demonstrate value that can translate across disciplines in oncology and within an evolving health care system.

ACKNOWLEDGMENTS
We are grateful for the help of Marie-Jasmine Parsi in sourcing the full-text articles for review, Isabelle Gaboury for reviewing the search protocol and suggesting possible information sources, and information specialist Jessie McGowan for conducting the systematic search.We also extend our thanks to the people from the integrative oncology programs who responded to our questions and to the experts we approached for providing citations to investigate.This study is supported by a grant from the Lotte and John Hecht Memorial Foundation.

CONFLICT OF INTEREST DISCLOSURES
None of the authors has any financial conflicts of interest to declare.

figure 1 prisma
figure 1 prisma diagram of article flow throughout the systematic review.

figure 2
figure2 Complementary therapies offered within integrative oncology programs.Other therapies offered within 2 or fewer programs, and not represented in this figure, include dance therapy, herbal medicine, integrative medicine consultations, life coaching, relationship counselling, naturopathic medicine, Pilates, biofeedback, sound therapy, machine therapy, chiropractic, electrochemical therapies, enemas, healing garden, hyperthermia, orthobionomy, physiotherapy, quartz crystal bowls, Tibetan bowls, special baths, and Traditional Chinese Medicine.

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Current OnCOlOgy-VOlume 19, number 6, DeCember 2012Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).
Complementary Therapies in Medicine, Alternative Therapies in Health and Medicine, Current Oncology, Complementary Therapies in Clinical Practice (formerly Complementary Therapies in Nursing and Midwifery), Alternative Medicine Review, Alternative and Complementary Therapies, Integrative Cancer Therapies, and Journal for the Society of Integrative Oncology] and hand-searched published abstracts from four complementary and integrative medicine conferences (Society for Integrative Oncology, North

). Each program incorporates e439 Current OnCOlOgy-VOlume 19, number 6, DeCember 2012 Copyright
© 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

Table ii
provides a brief description of the process of care within each program.figure 3 Components of care and organizational structure within integrative oncology programs.nr = not reported.

e442 Current OnCOlOgy-VOlume 19, number 6, DeCember 2012
Description of organizational structure and operations for integrative oncology programs The im team is part of the mskcc health care team and collaborates with physicians, nurses, and other health professionals to ensure appropriate treatment plans.All interventions and patient encounters are properly charted in a shared medical record.Accreditation and standards for complementary medicine practitioner: State licensed or nationally certified; extensive relevant experience, and trained in basic cancer concepts.Massage therapists attend mskcc-developed 2.5-day certificate course to prepare for work with cancer patients, including patient evaluation and development of a treatment plan, training the family, and serving as a member of the oncology team.Day-to-day funding and operations: Initially through start-up funds from interested donors and support from the mskcc operating budget.All personnel costs are through the im budget.Research grants and philanthropic donations provide remaining operational funds.
[21][22][23]2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).Complementary therapy cost recovery: All outpatient treatments are fee-for-service.Massage, music therapy, and meditation are free of charge to inpatients at Memorial Hospital.Research program description: Two-pronged research effort includes studies to evaluate the ability of specific complementary therapies to reduce cancer-and cancer treatment-related symptoms, and the investigation of botanicals for potential antitumour effects.Block Center for Integrative Cancer Care[21][22][23]Evanston, IL, U.S.A.  1985Means for practitioner collaboration: Weekly Tumor Board meetings between oncology and nursing teams.Common access to patients' electronic medical records that include information on complementary and conventional interventions alike.All staff in the same clinic, and sometimes share office space.Research program description: Whole-systems research, qualitative research, stage i and ii trials Breast Health Center 24 Cancer Treatment Centers of America 21,25,26 IL, WA, OK, PA, and AZ, U.S.A. 1988 Hospital-based Means for practitioner collaboration: Formal group meetings with complementary and conventional practitioners throughout the week to discuss specific patients and their progress.Tumour board meets once weekly to discuss current cases.Multidisciplinary "Comfort Rounds" to inpatients asking the questions "Are you comfortable?" and "What can we do to make you more comfortable?"Shared patient charts.Accreditation and standards for complementary medicine practitioner: All naturopathic doctors and acupuncturists must be licensed in a licensing state.Day-to-day funding and operations: Third-party billing, donations, and patient payment for chemotherapy, surgery, and radiation.Palm Harbor, FL, U.S.A. 1998 Community-based Current OnCOlOgy-VOlume 19, number 6, DeCember 2012 Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

table ii
Description of patient care and flow in integrative oncology programs e448 Current OnCOlOgy-VOlume 19, number 6, DeCember 2012 Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).e449 Current OnCOlOgy-VOlume 19, number 6, DeCember 2012 Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).nr e450 Current OnCOlOgy-VOlume 19, number 6, DeCember 2012 Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).e451 Current OnCOlOgy-VOlume 19, number 6, DeCember 2012 Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).nr Current OnCOlOgy-VOlume 19, number 6, DeCember 2012 Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

Current OnCOlOgy-VOlume 19, number 6, DeCember 2012
Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

VOlume 19, number 6, DeCember 2012
Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

Current OnCOlOgy-VOlume 19, number 6, DeCember 2012
Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

e461 Current OnCOlOgy-VOlume 19, number 6, DeCember 2012
Copyright © 2012 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).