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Patients under palliative care, facing poor prognoses and a heavy symptom burden, often seek health-care practices and agents outside of mainstream medicine. Collectively these modalities often are termed ‘complementary and alternative medicine’ (CAM), to describe a diverse group of therapies that range from unproved alternative ‘cures’ offering false hope, to adjunctive complementary therapies that provide legitimate supportive care and that comprise integrative oncology. Although complementary therapies and alternative approaches are sometimes discussed under the single umbrella of CAM, it is clinically and conceptually necessary to distinguish between complementary and ‘alternative’ because they are profoundly different, and because there are no viable ‘alternatives’ to mainstream cancer care. The acronym is an easy but incorrect and counterproductive conflation of two unrelated approaches. This chapter summarizes the state of integrative medicine and medical oncology in the current health-care system. It discusses helpful complementary therapies applicable to palliative medicine and also describes the unproven alternatives that are widely proffered to patients and families internationally.

An informal review of literature on exercise and cancer was undertaken in order to examine the role of exercise in cancer prevention, treatment, rehabilitation, and late survivorship. Population-wide studies show that cancer incidence decreases with increasing physical activity levels. Exercise can decrease the side effects of anticancer therapy, and can aid in recovery and rehabilitation following chemotherapy, radiation, and surgery. Observational studies of breast, colon, and prostate cancer survivors show robust associations between post-diagnosis exercise and decreased cancer-specific mortality. In addition, all-cause mortality in cancer survivors decreases with increasing amounts of exercise. The amount and intensity of exercise required to measure a survival benefit appear to vary by primary tumor type. Decreased breast cancer mortality is seen with the equivalent of 3 hours of walking per week, and decreased colon cancer mortality with 6 hours of walking per week. For these tumors, more vigorous exercise may not improve survival. However, after a prostate cancer diagnosis, more intense exercise is associated with superior survival when compared with walking. The mechanisms behind these differences remain to be elucidated. Further research is also needed to determine the various amounts and intensities of exercise required for optimum cancer prevention, recovery, and survival.

Complementary therapies are adjuncts to mainstream care, used primarily for symptom control and to enhance physical and emotional strength during and after mainstream cancer treatment. These therapies are rational, noninvasive and evidence-based that have been subjected to study to determine their value, document the problems they aim to ameliorate and define the circumstances under which they are beneficial. By contrast, 'alternative' therapies are generally promoted as such-for use as actual antitumour treatments. Typically they lack biological plausibility and scientific evidence of safety and efficacy, and many are outright fraudulent. Combining the helpful complementary therapies with mainstream oncology care to address patients' physical, psychological and spiritual needs constitutes the practice of integrative oncology. By providing patients' nonpharmacological treatment modalities that reduce symptom burden and improve quality of life, physicians enable patients to have an active role in their care, which in turn improves the physician-patient relationship, the quality of cancer care and the well-being of patients and their families.

A well-informed oncologist can guide patients to use complementary treatments to maximize benefits and minimize the risk of harm. Patients need help to steer away from problematic alternatives that are worthless or dangerous. We want to help patients receive beneficial complementary modalities because they extend supportive care, and we certainly want to know more than most of us now do about herb-drug interactions.

The integration of traditional, complementary, and integrative medicine (CIM) in contemporary cancer care is an emergent field of clinical practice and research throughout the world. The use of herbs, nutrition, mind-body, and spiritual practices is deeply rooted in the cross-cultural mosaic of Middle Eastern and South Asian nations. The concept of integrative oncology has emerged in the last decade to signify the need to amalgamate traditional and complementary medicine practices with evidence-based research aiming to improve supportive cancer care. The integration of ancient roots with contemporary scientific sprouts is not merely a metaphor but a significant tool for promoting holistic patient-centered care that emphasizes patients' well-being rather than focusing merely on cancer cells and disease-centered terminology. Indeed, the remarkable achievements in contemporary integrative oncology only emphasize the need for a patient-tailored strategy of care attuned to the individual's biophysical, psychological, social, cultural, and spiritual needs and concerns. The integrative challenge is how to provide an evidence-based consultation and supportive treatment to patients who confront fear at the moment of breaking the bad news of cancer diagnosis; how to improve their well-being during chemotherapy, radiation, surgical, or palliative treatment; and how to support patients and their care providers along the survivorship pathway or across the threshold of life. In daily practice, integrative oncology may be employed to reduce nausea and vomiting (e.g., use of the traditional Ayurvedic and Chinese herb Zingiber officinale known as ginger [1]), to alleviate pain (e.g., acupuncture [2]), and to improve fatigue (e.g., exercise, relaxation and body awareness training combined with massage [3]), mood disturbances (manual modalities [4]), and many other disease symptoms and chemotherapy side effects. Integrative oncology is also challenged by the need to obtain CIM safety (e.g., awareness of the risks of herbal-chemotherapy interactions) and high-quality standards of CIM supplements as well as professional training of integrative practitioners. Last but not least, these fundamental elements need to be enhanced by open communication channels between CIM practitioners, oncologists, and other health care providers in order to conclude a comprehensive integrative approach based on vibrant multidisciplinary discourse. Hence, the concept of integrative oncology goes far beyond traditional, alternative, or complementary practice, signifying a call for holistic practice, a whole that is larger than the sum of its scientific, clinical, and humanistic parts. The paper by H. Zaid et al. featured in this special issue reviews the concept of traditional Islamic medicine with regard to herbs with potential anticancer activity. This paper illuminates the importance of bridging ancient knowledge rooted in Greco-Arabic medicine and contemporary research. But, in addition to the extensive review presented by H. Zaid et al., this paper is also distinctive thanks to the contribution of the two other authors in this collaborative Israeli-Palestinian paper. Notable is the contribution of M. Silbermann, the director of the US National Cancer Institute-affiliated Middle-East Cancer Consortium (MECC), who has succeeded over the last 15 years in promoting supportive care collaborations that have included joint integrative oncology projects between MECC (Egypt, Israel, Palestinian Authority, Jordan, Turkey, and Cyprus) and other Middle-Eastern countries [5, 6]. The paper by E. Ben-Arye presents an integrative oncology program operated within conventional oncology services in northern Israel aimed at improving patients' quality of life during chemotherapy and advanced cancer. The authors address barriers to integration of traditional and complementary medicine in supportive care of Arab patients and propose six practical recommendations aimed at improving patients' access to integrative supportive care as well as compliance with treatments. This paper emphasizes the need to base integrative oncology on a sensitive cross-cultural approach that takes into consideration social, cultural, and spiritual elements. The paper by M. Schaltz et al. intensifies this cross-cultural theme by reflecting on palliative care from the perspective of Jewish and Islamic traditions. The collaboration in this paper between M. Schultz and K. Baddarni, two scholars in spiritual supportive care in northern Israel, highlights the richness of therapeutic dialogue between Muslim and Jewish health care providers who share faith in the role of the integrative dialogue. This paper summarizes ethical, religious, and spiritual insights gleaned in the management of patients in the community-centered Al-Taj organization and in the oncology department in Rambam health care campus, which is named for the renowned Jewish physician Maimonides. The paper authored by I. Cantarero-Villanueva et al. from Granada presents the flavor of the ancient cities of southern Spain, the backdrop for the Golden Age of collaborative Muslim and Jewish physicians, including Maimonides and the followers of Ibn-Sina, the most prominent Islamic medicine scholar. In this paper, the authors evaluated, in a randomized controlled trial, the effects of a multimodal exercise and massage program on the well-being of breast cancer survivors. The reduced fatigue, tension, depression, and improved vigor and muscle strength after intervention and 6 months after discharge are remarkable and support the need for other rigorous trials in the integrative oncology field. Moving from West to East across the Mediterranean and West Asia, the paper by P. Puataweeponge et al. presents the notion of complementary medicine in Bangkok, Thailand. The authors present a study regarding CAM use by a large cohort of cancer patients attending outpatient radiotherapy treatment in Thailand. The high prevalence of CAM use of more than 60% is notable in light of the patient-oncologist communication gap illustrated by the high prevalence (58.3%) of patients who did not disclose CAM use to their doctors. This communication aspect should raise concern when 9.4% of patients in this study reported side effects of CAM treatments. Moreover, this study emphasizes the need for a paradigm shift from CAM (with emphasis on alternative) to CIM (with emphasis on integrative) that will enable patients and physicians to discuss complementary use in an open nonjudgmental context. Two papers in this issue present the fundamental in vitro research elements needed to base any clinical integrative oncology activity. Zhang et al. from China report. the anticancer effects of the photochemical Zerumbone, isolated from the plant Zingiber zerumbet Smith. Although additional rigorous studies are warranted, the promising apoptosis induction effect of this plant on pancreatic carcinoma cell lines may suggest that ginger and related plants may have anticancer properties in addition to their beneficial effect in chemotherapy-related nausea and vomiting. In the paper by Y. H. Liu et al. from neighboring Taiwan, they studied Abrin, a protein purified from the seeds of Abrus precatorius, and reported that prohibitin, a tumor-suppressing protein, plays a role in abrin-induced apoptosis. These findings join the growing number of promising studies in integrative oncology that may support development of new and, in some cases, traditional medicine-based, therapeutic agents and modalities for the benefit of patients with cancer across the globe.

The berries of Lycium barbarum, a perennial plant native to Asia and southeastern Europe, have been used for centuries in traditional Chinese medicine to treat poor vision, anemia, inflammation, and cough. They are also consumed as food and used in soup recipes. Lycium has gained immense popularity in the United States over the past decade because of its antioxidant properties. It is available in health food stores and is marketed via the Internet in juice form, typically blended with the juices of other berries and fruits. A wide range of health benefits, including cancer prevention and treatment, have been claimed for lycium.

Lycopene is a carotenoid found in grapefruit, watermelons, and papaya in addition to tomatoes. It is obtained only through diet. Lycopene exhibits antioxidant and anticancer properties. Results from several epidemiologic studies suggest a strong association between high intake of lycopene-rich foods and reduced risk of several cancers, notably prostate cancer. However, few well designed clinical trials have been conducted, and data remain inconclusive. Because lycopene supplementation is associated with strong antioxidant effects, it has the potential to interfere with chemotherapy and radiation therapy. Cancer patients should use caution if considering an increase in their lycopene intake.

The Gerson regimen, developed by Max Gerson in the 1930s, is promoted as an alternative cancer treatment. It involves consuming fresh, raw fruit and vegetable juices, eliminating salt from the diet, taking supplements such as potassium, vitamin B12, thyroid hormone, pancreatic enzymes, and detoxifying liver with coffee enemas to stimulate metabolism. Gerson therapy is based on the theory that cancer is caused by alteration of cell metabolism by toxic environmental substances and processed food, which changes its sodium and potassium content. It emphasizes increasing potassium intake and minimizing sodium consumption in an effort to correct the electrolyte imbalance, repair tissue, and detoxify the liver. The coffee enemas are believed to cause dilation of bile ducts and excretion of toxic breakdown products by the liver and through the colon wall. None of these theories has been substantiated by scientific research. Despite proponents' claims of recovery rates as high as 70% to 90%, case reviews by the National Cancer Institute (NCI) and the New York County Medical Society found no evidence of usefulness for the Gerson diet. An NCI-sponsored study of Gonzalez therapy, which is similar to the Gerson diet, showed that patients with inoperable pancreatic adenocarcinoma who underwent standard chemotherapy with gemcitabine (Gemzar) survived three times longer and had better quality of life than those who chose enzyme treatment, which included pancreatic enzymes, nutritional supplements, detoxification, and an organic diet.

There are important safety concerns associated with dietary supplements and foods rich in phytoestrogens, especially for breast cancer patients with hormone-sensitive disease. However, no consensus has been reached concerning specific dietary items that should be avoided, and safe levels of potentially problematic foods have yet to be determined. Excellent qualitative reviews of phytoestrogens and breast cancer have been published. These list agents that contain phytoestrogens and offer general cautions. Quantitative reviews, however, are needed but not yet available. Here we review quantitative data on phytoestrogens, their interaction with estrogen receptors, their bioavailability and pharmacokinetics, and their effects on breast cancer cells and animal models. We also note foods and botanicals with substances that interact with estrogen receptors and discuss the phytoestrogens they contain. Based on current evidence, we propose recommendations for advising breast cancer patients, which may also serve as a basis for the development of clinical practice guidelines.

Omega-3 fatty acids are essential compounds involved in several important physiologic processes. They are not synthesized in the body but can be obtained through diet or by taking dietary supplements. Fatty fish and nuts are excellent sources of omega-3.

Oxygen therapies are unproven alternatives promoted as a cure for cancer, acquired immune deficiency syndrome (AIDS), and other degenerative diseases. These "therapies" are offered at clinics in Mexico, the United States, and Europe. Proponents claim that many diseases, including cancer, are caused by oxygen deficiency and that oxygenation can restore health by destroying cancer cells, eliminating pathogens, stimulating metabolism, and by producing "oxidative detoxification." There is no scientific evidence to support any of these claims. Oxygen therapies include: (1) hydrogen peroxide therapy involving intravenous infusion, ingestion, colonic administration, or soaking in hydrogen peroxide solution; (2) ozone colonies and ozone autohemotherapy, in which blood is withdrawn and treated with ozone before reinfusion, and (3) "oxygenated" water, pills, and solutions. The use of oxygen therapies has resulted in serious adverse events and several deaths. Oxygen therapies should not be confused with those commonly used in respiratory care.