By Omid Etemadi, MD
Executive Director, CancerCare Cancer Supportive Care Philippines
Author’s note: This article is written to highlight the University of Arizona’s pioneering work in educating medical professionals around the globe on the importance of continually transforming healthcare. As the Integrative Medicine Program of the University of Arizona turns 25 this year,1 the passion and drive for holistic care grows palpably stronger.
After I completed my fellowship training at the University of Arizona Center for Integrative Medicine in 2011, I went back to my home country, the Philippines. I did not know how the local medical community would react to the introduction of integrative medicine. On one hand, the need was clear and present. The Philippines is one of the most densely populated countries per square mile with a population of over 100 million and growing, and it has one of the highest cancer incidence rates in Asia.2 An integrated care delivery system is a glaring hole to fill. On the other hand, care delivery has historically been fragmented and each medical specialty had been intrinsically independent. Cancer survivorship planning was a vague unrecognized term and patient navigation was nonexistent. Integrative medicine was also a very loosely used term, often confused with alternative medicine. The challenge ahead was daunting.
In June 2012, I began the arduous task of trying to convince medical society groups to adopt to a more integrated, interdependent system of care delivery. I first approached the Philippine Society of Medical Oncology, the largest group of board-certified cancer specialists in the country. To my surprise and broad relief, the group was very receptive to holistic care approaches. Drs. Noemi Alsay-Uy and Ellie May Villegas, then past presidents of the PSMO, were very instrumental in laying the foundation for integrative oncology in the Philippines.
Our first order of business was to identify other physician specialists and allied health practitioners in the community. Next, we had to create a pilot site on which other centers would be patterned. Thus, after much deliberation, the CancerCare Survivorship Center was formalized in the summer of 2012. The center became the country's pilot site for advocacy, education, and integrated cancer care delivery.3 All patients would undergo psychological care/family counseling and nutrition/cachexia management, and patient education lectures were offered on chemotherapy side-effect management and complementary/alternative medicine. Palliative and home/hospice care were also available for patients with locally advanced or metastatic disease.
Through years of advocating for integrative care, we learned that the constant and recurring hindrance to full nationwide implementation is indeed financial cost. Both patient and referring physician perception of an additional financial burden incurred through full-scale supportive care was an obstacle. We thus turned to the literature to learn from other experiences worldwide. A very well-written piece by Reid et al. of Yale University showed that low-cost palliative and supportive care was very attainable in middle- to low-income countries.4
We modified some of our protocols in response to the paper’s recommendations. Our new low-cost patient care delivery system was then put in place. A patient navigator would now screen patients using the Edmonton Symptom Assessment Scale (ESAS). 5 Consults would only be given for areas of concern (mood, sleep disturbance, pain, appetite, etc.) based on the ESAS assessment. Patient education lectures were delivered free of cost. We were able to streamline operations and focus our energies better, thankfully with wider acceptability from both patients and referring physicians.
Our protocols have also evolved through the years, most especially in response to ASCO's update of survivorship care and palliative care guidelines. Oncology is a rapidly evolving field and protocols must be quick to adapt to such changes. Local practices and other variances in the community setting must likewise be accounted for. We found the ASCO Resource-Stratified Practice Guideline on Palliative Care in the Global Setting to be extremely helpful.6 The ASCO Educational Book article “Using the New ASCO Clinical Practice Guideline for Palliative Care Concurrent With Oncology Care Using the TEAM Approach” is likewise enlightening.7
Beyond our pilot site clinic work, nationwide advocacy in collaboration with PSMO had to be rigorously undertaken. For the past 7 years, I have conducted over 100 lectures advocating for an integrated health care management system in oncology. Audiences ranged from town hall meetings with patient support groups, national meetings with advocacy organizations, and international oncology symposia.8-10 I worried that although I had convinced enough organizations about the importance of integrative care, we were not seeing enough impactful actionable change.
Above: Dr. Etemadi delivers a lecture on integrative cancer care.
To the collective relief of my PSMO colleagues and I, our advocacy work had not fallen on deaf ears. Cancer Coalition Philippines, the largest oncology patient support group in the country, started pressing the Philippine Congress of the importance of universal access for Filipinos to comprehensive, integrated cancer treatments. Senators and Congressional representatives finally understood that the negative community impact of cancer was drastically more severe than that of other chronic, non-communicable diseases. The Technical Working Group started drafting the National Integrated Cancer Care Act (NICCA) on December 7, 2017, and the act was subsequently ratified by Congress on December 13, 2018. Philippine President Rodrigo Duterte officially signed RA11215 promulgating NICCA into law on February 14, 2019. The Department of Health released implementing rules of the NICCA law on August 19, 2019, and tasked Philhealth, the country's government-owned and -operated insurance corporation, with providing universal coverage of patient treatments including supportive care services.11
We were ecstatic that integrative care features prominently in the new NICCA law and is the first parameter mentioned. The Philippines thus became the first country in Southeast Asia that has a national law specifically dedicated to the advancement of holistic oncology care. Similarly, on September 26, 2019, the Philippines was recognized as the first focus country in the Western Pacific for the World Health Organization’s Global Initiative on Childhood Cancer. 12
In summary, nationwide integrated holistic oncology care is attainable. It requires tremendous commitment and effort through community advocacy, nongovernmental organization/government collaborations, partnerships, and policy.
Dr. Etemadi is a specialist in integrated oncology health care management. He has been the executive director of CancerCare Cancer Supportive Care Philippines for the past 8 years. He completed his fellowship in integrative medicine at the University of Arizona and completed the Accelerated Management Program at Yale University. He is a member of ASCO and of the Arizona Clinical Oncology Society.
- Duschek C. Modern medicine trailblazers: Celebrating 25 years of the Andrew Weil Center for Integrative Medicine. The University of Arizona Alumni Association.
- International Agency for Research on Cancer, World Health Organization. Population Fact Sheet: Philippines. Global Cancer Observatory. Globocan 2018.
- Cancer center opens in Cebu. Philippine Daily Inquirer. Jul 30, 2012.
- Reid EA, Kovalerchik O, Jubanyik K, et al. Is palliative care cost-effective in low-income and middle-income countries? A mixed-methods systematic review. BMJ Support Palliat Care. 2019;9:120-9.
- Hui D, Bruera E. The Edmonton Symptom Assessment System 25 Years Later: Past, Present, and Future Developments. J Pain Symptom Manage. 2017;53:630-43.
- Osman H, Shrestha S, Temin S, et al. Palliative Care in the Global Setting: ASCO Resource-Stratified Practice Guideline. J Glob Oncol. 2018;4:1-24.
- Smith CB, Phillips T, Smith TJ. Using the New ASCO Clinical Practice Guideline for Palliative Care Concurrent With Oncology Care Using the TEAM Approach. Am Soc Clin Oncol Educ Book. 2017;37:714–723.
- Quality and integrative care in managing cancer. Philippine Star. Jun 24, 2013.
- Life can be better: Living with, through and beyond cancer. GMA News Online. Jul 2, 2013.
- Jambora AA. ‘Guyabano’ and supplements alone won’t beat cancer, doctors say. Philippine Daily Inquirer. Oct 13, 2018.
- Cairo CU. Next Frontiers in Philippine Oncology and Development in the Entire Cancer Care Continuum from Prevention to Management. Ann Oncol. 2019;30 Suppl 6: mdz309.
- Paunan JCR. WHO: PH now 1st focus country for childhood cancer global initiative. Philippine Information Agency. Sep 26, 2019.