The Arab population in Israel is characterized by a rich mosaic of communities distinguished by religious, social, and cultural elements. Arabic-speaking Israeli citizens include Muslims, Christians, and Druze who together constitute the largest minority group in Israel (according to the 2014 Census, about 1.7 million), comprising roughly 20.7 % of the country’s total population [1]. This large and diverse population is often defined by the Israeli political establishment as “Israeli-Arabs” based on their right to Israeli citizenship, as opposed to Palestinian communities residing outside the sovereign borders of Israel (e.g., about 77 % of the world’s population of Palestinians are residing in the West Bank, Gaza Strip, Arab, and non-Arab countries) [2]. There is considerable agreement that Arabs in Israel represent a distinctive population group compared with both the Jewish Israeli population and the Palestinian population outside Israel and other Arab countries. This unique social-cultural identity, which originated as a result of the 1948 War, has generated an impressive sociocultural and lifestyle transition, manifested in population morbidity, health outcomes and life expectancy [3], including the arena of oncology.

In 2006, the Middle East Cancer Consortium (MECC) published a comprehensive monograph of its Cancer Registration Project concerning cancer incidence during the period of 1996–2001 in four of its six member countries (Cyprus, Egypt, Israel, and Jordan) [4]. The authors reported that overall incidence of cancer was substantially higher in the Jewish-Israeli and the US Surveillance, Epidemiology, and End Results Program populations, compared with the Israeli-Arab population (assessed with intermediate rates) and with Cypriots, Egyptians, and Jordanians. Overall age-standardized incidence rates per 100,000 population was 274 in Israeli Jews compared with 149 in Israeli-Arabs, 143 in Egyptians, and 113 in Jordanians. Nevertheless, studies published in the last decade in Israel indicate a dramatic surge in cancer incidence of Israeli-Arabs who had until recently been regarded, along other Arab communities, as having a lower cancer risk. Keinan-Boker and her colleagues (2013) examined breast cancer trends in Israeli Jewish and Arab women and reported that from 1996 to 2007, the incidence of invasive breast cancer increased by 98 % for Arab women while simultaneously decreasing by 3 % for Jewish women [5]. The authors observed that breast cancer mortality rates remained stable in Israeli-Arab women while significantly decreasing in Jewish women. In the past decade, a similar trend of increased cancer incidence in the Israeli-Arab population, compared with the Jewish population, has been reported in left-sided colorectal [6] and gastric [7] cancer.

Aiming to explain the increase in cancer prevalence among the Israeli-Arab population, researchers hypothesized a correlation with environmental factors, particularly lifestyle changes characterizing the sociocultural metamorphosis the Arab community has been experiencing between traditional and westernized lifestyles and health models. Although evidence for the linkage between lifestyle and cancer incidence in the Israeli Arab population is limited, several studies suggest a probable correlation. A case control study conducted in northern Israel revealed a significant inverse association between a Mediterranean diet and cancer prevalence in Arab participants [8]. Probable lifestyle changes were also hypothesized by researchers reporting on altered incidence and sites of colorectal cancer in the Israeli Arab population [6] and of an increase in lung cancer incidence among Israeli Arab men without evidence of increased smoking prevalence [9]. Other potential cancer-associated lifestyle changes yet to be probed in the Arab community in Israel include stress-related modernized settings, a tendency towards distancing from traditional codes and familial bonding, and gender-associated elements (e.g., attenuation of protective factors in breast cancer such as younger age of motherhood and breastfeeding).

Complementary medicine use among Arabs in Israel is predominantly related to traditional medicine, mostly herbs used for centuries with the aim of healing and ameliorating acute as well as chronic diseases. Traditional Muslim medicine, at times regarded as Greco-Islamic medicine [10], is rooted in historical Middle-Eastern schools of medical practice (ancient Egyptian, Mesopotamian, Greek, and Persian medicine) and influenced by the great East Asian medical schools of Chinese and Ayurvedic medicine in India. In the Middle Ages, Islamic medicine mediated between the Western and Eastern medical cultures and integrated hundreds of indigenous Mediterranean and Middle-Eastern herbs within a medical practice enriched by remedies brought from Europe and the Far East. The use of herbs was complemented by spiritual practices and manual techniques including massage and cupping.

Although complementary and traditional medicine (CTM) use is highly prevalent in the Israeli-Arab population as well as in other Middle Eastern Arab and Muslim societies, the line between traditional (al tibb al–taklidi), alternative (al tibb al–badil), and complementary (al tibb al–mukamel) concepts of medical care is often indistinct. In practice, many herbs are used in the Arab diet or regarded as an integral part of the Arab culture. Thus, a common herb like sage (Salvia fruticosa mill) is frequently used throughout the year as a beverage but may also be applied to cure specific ailments such as abdominal pain. Aiming to explore the prevalence of CTM use (for medicinal purposes) in the Israeli-Arab population, researchers studied perspectives of 2184 Arabic-speaking patients (Muslims, Christians, and Druze) attending primary care clinics in northern Israel. Arab and Jewish respondents reported comparable overall CTM use during the previous year (above 40 %), but Arab respondents reported greater use of herbs and traditional medicine [11]. This high prevalence of CTM use reported in primary care was also documented among Arab patients confronted with cancer diagnosis and treatment. A study of 324 Arab patients in the oncology setting revealed that nearly 40 % of patients reported CTM for cancer-related outcomes [12]. Moreover, CTM use was correlated with active chemo/radiotherapy treatment and a higher degree of spiritual quest. As in the primary care setting, herbal medicine was the prominent CTM modality of choice (reported by nearly 90 % of CTM users). In the present study, more than 80 % of respondents supported integration of a complementary medicine consultant within the oncology department mainly to improve their quality of life (QOL) including gastrointestinal symptoms, fatigue, and pain, alleviating chemotherapy’s side effects and enhancing their coping with the disease.

Patients’ expectation to integrate complementary medicine within their conventional supportive cancer care is shared by many patients worldwide in various phases of cancer treatment, be it active treatment for local disease (e.g., surgery, chemotherapy, radiotherapy, hormonal, and biological treatments), during surveillance, or palliative care for widespread metastatic cancer. In the past decade, leading oncology centers in the US and Europe have integrated complementary medicine services within conventional care settings aiming to provide evidence-based consultation and treatments to improve patients’ QOL [13, 14]. A new paradigm of integrative oncology has been introduced calling for improved patient-doctor dialogue on CTM use, a nonjudgmental patient-centered approach, and the need to ensure the safety of complementary practices (e.g., avoiding risk of detrimental herbal supplement/chemotherapy interactions) [15, 16].

In 2008, an Integrative Oncology Program (IOP) was launched as a free-of-charge clinical service within the Clalit Health Organization’s oncology service at the Lin Medical Center (Haifa, Israel) aspiring to improve patients’ QOL during chemotherapy and advanced disease state [17]. Patients are referred by their oncology care practitioners (oncologist, oncology nurse, or psycho-oncologist) to an initial consultation with integrative physicians (IPs) dually trained in conventional care and CTM. Typical IP assessment includes evaluation of patient’s expectations regarding CTM, previous CTM experience, and QOL status. The session concludes with an outlining of the treatment goals followed by construction of a treatment plan tailored to the patient’s expectations, concerns, and health belief model, level of scientific evidence (efficacy, safety, possible interactions with chemotherapy, etc.), and feedback of the patients’ oncologist, family physician, nurse, and psycho-oncologist. Patients are typically scheduled for weekly integrative treatments that may include herbal medicine and nutritional counseling, mind-body and manual therapies, spiritual care, acupuncture, Anthroposophic medicine, and other CTM modalities. Prior to therapeutic sessions, an additional clinical assessment is conducted, aimed to modify, if necessary, the treatment goals and plan. Concluding QOL assessments are performed during initial and follow-up visits aiming to monitor patients’ concerns, changes, and impact of the integrative treatment on their well-being.

In the first years of the IOP’s activity, more than 500 patients were referred to IP consultations. Yet, compared with Jewish patients, the number of referred Arab patients was significantly smaller and continuity of integrative care was achieved more rarely. Attempting to identify barriers to optimal integrative care in Arab patients, the IOP practitioners analyzed a cohort of 15 patients monitored through a registry protocol [18]. The main barriers identified included the following: (1) limited oncology care practitioners’ referral to IP consultation; (2) patient-related factors (e.g., patients expecting CTM to “cure” them rather than “just” improve their QOL); (3) factors determined by the medical institution (e.g., geographical factors that limit Arab patients’ access to the IOP service; limited patient–practitioner communication due to the small number of Arabic-speaking practitioners within the oncology service and the IOP team).

Aiming to identify better potential barriers to optimal integrative treatment for Arab patients with cancer, IOP researchers initiated additional studies targeting three stakeholders: (1) patients (compared cohorts of Israeli-Arab cancer patients from northern Israel and Palestinian cancer patients from the town of Nablus, in the Palestinian Authority) [19]; (2) oncology practitioners and researchers from seven Middle Eastern countries [20, 21]; and (3) Israeli-Arab CTM providers experienced in treatment of Arab patients with cancer [22–24]. The three angles of exploration suggested repeatedly an inevitable need to base an integrative oncology model for Arab patients on a cross-cultural perspective. In contrast to the individual-oriented perspective emphasized in integrative oncology centers in the West (patient-centered approach), we perceived a need for a supplementary community-oriented approach that would also address the unique bio-psycho-cultural-religious-spiritual dimension of patients from distinct Arab communities. In the following sections, we wish to illustrate the daily challenges we confront with Arab patients in our integrative oncology setting in Haifa and to suggest strategies to integrate a patient-tailored approach attuned with the patient’s and caregivers’ cultural, community, and health care model.

Manal, a 56-year-old married woman, was referred by a nurse oncologist to an integrative oncology consultation aiming to alleviate emotional distress prior to administration of chemotherapy (Adriamycin and Cytoxan) scheduled the same morning in the oncology department. Manal had been recently diagnosed with local breast cancer but was advised to receive neo-adjuvant chemotherapy prior to surgical lumpectomy. The initial consultation was provided by an IP, a family physician trained in complementary/integrative medicine, and a spiritual care provider who assessed Manal’s expectations and concerns, seeking to co-identify treatment goals and construct a preliminary treatment program. Assessment of the patient’s narrative and health belief model revealed a sense of transformational experience. Manal, who until recently had experienced good health and a promising career as a senior academic lecturer, felt that the new cancer diagnosis did not only challenge her well-being but also focused her attention inwardly to “my body that now demands attention.” During the following appointments, the IP reassessed Manal’s concerns, focusing on chemotherapy-induced fatigue, nausea, and the metallic taste in her mouth. Integrative treatment included consultations on herbal medicine and nutrition, some of which were familiar to Manal as an Arab-Christian from traditional Arab medicine and the Palestinian cuisine (e.g., Carob paste to alleviate mouth sores), and weekly acupuncture sessions combined with manual therapy and discussions with the spiritual care provider. Following 6 weeks, an interim IP assessment documented a moderate aggravation of pain, fatigue, nausea, and sleep, possibly related to the increasing impact of the third chemotherapy cycle on the patient’s well-being. In contrast to her seemingly deteriorating well-being, Manal regarded her situation as “the best thing in life” and characterized the integrative treatment as “medical support that gives me energy and hope.” The gap between the formal QOL questionnaires based on visual analogue scales and Manal’s documented narrative illustrates one of the important challenges in the integrative clinical setting: a need for a bio-psycho-social-cultural approach enabling better assessment of the therapeutic process. The interaction between Manal, the IP, and the spiritual care provider reflects, on the one hand, a patient-practitioner dialogue focusing on Manal’s individuality and striving to tailor the treatment plan to the patient’s concerns. However, on the other hand, Manal is an individual active in a broader society of an Arab minority in Israel encountering the tension between traditional collective identity and a more Western call for individuality. In this context, Manal does not represent merely herself as an individual but also carries collective values that may impact her expectations towards integrative treatment as well as her readiness and openness to assess her physical and emotional concerns during the first IP evaluation. A qualitative assessment tool is highly essential in this cross-cultural context, in addition to quantitative questionnaires aiming to expose the sub-textual realm of therapy. With this in mind, Manal’s main expectation along the weekly integrative treatments was “to strengthen myself” rather than merely alleviate cancer-related fatigue. The integrative treatment supported Manal in her quest for healing through the vale of “death that encircles me,” by acknowledging her journey as an individual, woman, mother, and academic leader in a transforming Arab society where she encounters an interplay of collective and individual values. In this context, Manal represents a group of independent, highly educated Arab women who can quite easily relate to integrative medicine of the kind that is offered within the oncology service at the Lin Medical Center in Haifa.