How would you initiate a conversation with an oncology patient about the use of herbal medicine? How would you bring up the use of herbal medicine with a patient during an integrative oncology consultation? Dr. Rossi will talk about his experience in Italy with patients who are either telling their doctors about their use of herbal medicine during cancer care or else keeping this information to themselves. People are coming from the counter, the mountain, etc. Okay. But in general, there is much high level of knowledge of complementary medicine. One consequence of this, that this is more acceptable complementary medicine from the medical convention and medical establishment. For instance, 67 percent of oncological patient can speak freely with their oncologists that they are using complementary medicine without any consequence. Including herbs? Including herbs. Do you have any experience with this question? How would you get the patients with cancer in your country to talk freely about the use of herbal medicine, especially among those who are currently undergoing active oncology treatment? In our earlier lectures, we discussed the high prevalence of herbal medicine use among oncology patients. Herbal remedies are being used at all stages of a disease, from the initial diagnosis to active neoadjuvant and adjuvant treatments and through survivorship or as part of palliative care in advanced disease. We've also talked about the historical and culture of origins of traditional herbal medicine, which date back to the ancient worlds of the Middle East, India, China and Europe. We have addressed the complexity of herbal medicine use in conjunction with conventional chemotherapy, surgery, and other oncology treatments. The use of herbal products during cancer care can be both effective when it comes to reducing the symptom load and improving quality of life, while at the same time, having safety related issues, which include side effects and negative interactions with conventional anticancer drugs. In this section, we will talk about ways in which we can create an environment in which there is an effective dialogue between the patient and the healthcare professional who is responsible for their care. These include oncologists, family physicians, surgeons, nurses, social workers, etc. All of whom need to be aware that many of their patients are using herbal medicine during conventional cancer treatments. In order to create such a setting, we need to first identify any existing gaps and barriers to effective communication and then search for ways in which we can overcome them. The end goal of this process will be the creation of an open and non-judgemental dialogue in which the evidence-based use of herbal medicine will be focused at promoting patient well-being without interfering with the conventional oncology treatment. We asked Professor Michael Silbermann, Executive Director of the Middle East Cancer Consortium, to talk about how communication with patients regarding the use of herbal medicine can promote the goals of palliative and support of cancer care as they relate to improving quality of life in general and specifically within the Middle Eastern context of care. I strongly believe that when we're talking about herbal treatment, this is more accepted by the patient than talking about very modern genetic molecular target organ treatment. So, therefore, and as I said, the first issue, if we care about a patient as a human being, is to build the trust, to build a common language, and thereby to show him that we respect him, his faith, his tradition, his habits, and we respect his wishes as far as we can. Let us consider a situation in which a patient, who has recently been diagnosed with cancer, has entered your consultation room for medical assessment and advice. In such a scenario, the goal would be to conclude the meeting with a structured treatment plan. Such a plan may include conventional modalities, such as surgery, chemotherapy, radiation therapy, biological or hormonal drug therapy, as well as supportive care treatment options. During this process, it will be extremely important and helpful if you are able to establish a rapport with the patient and with the oncology healthcare team. This would encourage the patient to ask questions, eventually advancing a decision-making process, which is patient-oriented and shared. Maybe we can sit with the oncologist as well. I don't know- Can you sit with him and, yeah. Maybe with you as well. Establishing rapport with patients is important not only for ethical reasons, but also in order to empower the patient during the share process of deciding the most optimal treatment plan, as well as increasing adherence to the oncology treatment regimen. We asked Dr. Elad Schiff on how physicians and healthcare practitioners can extract more information on the use of herbal medicine during their interaction with patients for both conventional, as well as integrative medicine treatments. I used originally the questionnaires that were used in other studies to assess the rate of use of dietary and herbal supplements in our medical centers. So, I provided those questionnaires to patients in the different departments. There was almost a zero percentage of patients declaring or telling us through those questionnaires that they are using herbal supplements. I was very surprised. How can that be? So, after receiving questionnaires from patients, I approach the patient who said that they are not using herbal supplements and starting to have a free chat with them about dietary and herbal supplements in different ways. I found out that patients are actually using herbal supplements, but they responded to the questions in the questionnaires in a negative answer. In order to create a rapport and promote a trusting dialogue with our patients, we need to assume that they are most likely using or else considering the use of herbal medicine as part of their cancer treatment regimen. This assumption, that the patient is most likely using herbal remedies, in addition to their conventional treatment, is an important step, in that it leads us to actively initiate an open and non-judgmental conversation about this practice, as opposed to waiting until the patient feels safe enough or interested enough to raise the question on their own. It is also our ethical and medical legal obligation to actively seek out information, which is relevant to our patients' health and well-being and not just be a watchful listener. Once a conversation on the use of herbal medicine during cancer care has been initiated, it should be assumed that, despite the open and non-judgmental environment, which has been created, that many patients may still be hesitant to disclose their use of these products or else may not be aware that the products they are using are considered to be herbal medicine. Patients are often reluctant to disclose their use of non-conventional modalities, including the use of herbal medicine, because of an anticipated negative, even deriding response from their healthcare professional. Some patients don't disclose their use of herbal medicines simply because they are not asked. When you start asking them about, "Do you use a grandmother herbs for your health?" or "Do you use vitamin C with specification of the type of the vitamin?" or "What natural products do you use for your health?" then patients will respond and reveal their use of dietary and herbal supplements. Finally, patients may neglect to mention that they are using herbal medicinal products in conjunction with their conventional cancer treatment for two main reasons. The first was mentioned before. Patients are often emotionally overwhelmed during the interaction with their health care professional to the extent that they do not associate the herbs they are using with the term herbal medicine use. This is because these herbs are used within the context of the local cuisine, or else as an herbal tea, or as their grandmother's special recipe, and so on. For example, a patient may be taking garlic or ginger, but because they are used as food, they may not consider them to be herbal medicine when asked about this practice. In order to prevent this misunderstanding, it would be helpful if during the history-taking, you would ask about specific herbal products, which are in widespread use among oncology patients in your region. For example, ginger and turmeric in Middle Eastern countries. In addition to mentioning specific herbs, patients should be asked about the use of herbal teas, herbs picked in the garden, herbs you recently added to your food, natural herbal juices, traditional medicine, etc. The question, "Have you changed your diet in order to treat your cancer?" Has been strongly correlated with the use of herbal medicine for cancer-related outcomes. We went systematic on this concept and ask naturopathic physician students to go into different departments and start asking the patients in a very open way, "Do use herbal supplements?" Then if the patients respond with a negative response, then they start to asking them in a culturally sensitive, open way about herbal remedies from grandmother, or things they pick in the garden for their health, or natural products, or specific names of vitamins and minerals. Actually, we found out that almost 50 percent, as you said, of patients are using herbal supplements during their hospitalization. We need to use those codes, those specific terms in the history-taking from patients to reveal such use. Why is it so important to ask patients? Because, as we said earlier, the use of herbal medicine during hospitalizations may cause interaction between the drugs and the herbs or the supplements. We actually found out that there is some 50 or 40-50 percent of patients having potential interaction, which is a bad interaction. Let's say if you take some herb, it may potentiate the blood thinning effect of the medication. Therefore, it is very important to understand if a patient is or is not using a herbal medication. So, you have to ask it sensitively, you have to be proactive in that, you have to document such use. We found out also that one in 55 hospitalizations is actually caused from a herb-herb or a drug-herb interaction. Questions about the use of herbal medicine need to be directed at both of these domains, as a treatment providing anti-cancer or immune-stimulating effects and as a treatment, which can reduce the side effects of conventional drugs while improving quality of life and function.