My name is Alfred Langler. I'm coming close from here. Herdecke is about 500 kilometers from Berlin. I work there as a pediatric oncologist, as an integrative pediatric oncologist. I did my pediatric oncology training in the University of Cologne. I'm the Head of Department of Pediatric and Integrative Medicine in the Gemeinschaftskrankenhaus since 2006, and now since 2013, I'm the Medical Director of the whole hospital. I think it's one of the biggest integrative hospitals in the world with 470 beds and our specialty is anthroposophic medicine together with other integrative methods present and just normal conventional medicine. And I would like to ask you how integration is in clinical practice in daily life? Yeah. Haematooncology, pediatric haematooncology. How does it look like and what happens to patients that come, to the parents? Yeah. How do they receive integrative care? Can you describe practically how it looks like? I can try. It's some kind of our everyday life that often we don't see but is intergrative because it's normal for us, integrative. So,the hospital is founded in 1969, so, it's now about, just 50 years running and it started from the first day from the first beginning was integrative medicine, conventional medicine, and anthroposophic medicine. The nurses, the doctors. They all are trained. The therapists are trained. Those in conventional medicine as in especially anthroposophic medicine. So, in our everyday life in pediatric oncology or pediatric haemato oncology, we don't have two worlds of conventional role and decritive or anthroposophic world. It's just one world, it's starts when you come into a hospital. You see colors on the walls. You smell may be some etheric oils. Maybe the sound would be another, I don't know, and it goes on with the people who are working there. They all are working integrative. We don't have an integrative team and conventional team. Every nurse, every doctor, every therapist knows those of his profession. So, for example, a child who's coming for chemotherapy, for acute Lymphatic Leukemia, we use the most of them don't know the DBFM protocol, and they come to get, for example, to get their Daunorubicin, Vincristine, and Asparaginase maybe. They get their Daunorubicin and Vincristine, but even they get anthroposophic medicine, anthroposophic therapies, anthroposophic remedies during chemotherapy and during their stay for the chemotherapy. Can you describe which herbal anthroposophic remedies you use? Yeah, the most prominent would be mistletoe therapy that what we are doing now since more than 30 years and we just finished a multi-center study where we included mistletoe, but other anthroposophic therapies to see what difference it makes in sense of toxicity. Data are not published yet, I hope we will publish them soon. You mean chemotherapy related toxicity? Yeah, or it mean not only chemotherapy related. I mean, we gave it together with chemotherapy, accompanying chemotherapy, so it may be toxicity of anthroposophic therapy as well, but mainly, it's toxicity of chemotherapy as well. So, the idea here is to prescribe herbal remedies? Yeah. In order to decrease the toxicity. Of conventional therapy. Yeah, so our control group only got conventional therapy and then we make this control. So, Viscum album and other herbal remedies, what is their potential to decrease which kind of? Well, what do I expect to in our daily life experiences that we may not have as much problems as other hospitals with vomiting and nausea. For example, we give Nux Vomica intravenously according to chemotherapy. It's off-label. We give things like our own. It's gold prunus. I don't know the expression for Prunus Spinosa. This is like an ointment? I mean, you give it as an ointment or IV? No, intravenously. Intravenously. Yeah, and Nux Vomica, I mentioned already. With starting chemotherapy together with H3 inhibitors, as everyone does like [inaudible]. Then, we give them every day during chemotherapy, but even in the breaks when they are at home, they get some homeopathic remedies like phosphorus, like [inaudible] , and symptom related for let's say, fatigue, let's say insomnia, let's say appetite loss. We have different possibilities to give some anthroposophic medicaments remedies as well, but on the other hand, we don't have only these tracks or drug medical treatment, even if the arts therapies like painting, like sculpturing, music therapy or even specific anthroposophic remedies therapy. So, how do you tailor herbal and other anthroposophical modalities treatment? I mean, is it symptom related? Is it chemotherapy related? Is there any relation to the individual symptom picture or unique? Yeah. So, it's all of them that what you are asking though. On the one hand, it depends on the individual. Which kind of individual I'll see. I'll see a child who is just very introverted, very calm, very close to his parents, or see a child who is very exciting, running around, no borders, seeing also, and then that's individualized therapy kind of, we call it, I don't know the English expression. Sorry. Okay. But, it's individualized, yeah. Is it according to the temperament? Yeah, that's what I was talking. The temperament, like the four temperaments. the architectural temperaments from the Greek. The constitutional, that's appropriate. Constitutional. Yeah. On the other side, we have some symptomatic treatment. If patient has appetite loss, we give special remedies to get more. Which remedies, can you? It's all these who smell bitter. So, for example, I told already, Cichorium. Cichorium. It's in a more herbal preparation five percent, it's not diluted. It's nice bitter. The other one is Gentiana lutea, it's Gentiana, don't know the English expression, sorry. Gentiana lutea. Yeah, it's very bitter, yeah. Some mixtures like Amara Drops, yeah. But, we should talk even about the external embrocations like stomach embrocations, and like giving some special substance like Oxalis to make an embrocation on the abdomen, things like that to get more appetite. It's one example. So, this is provided by the nurse. This provided by the nurse and the nurse itself gives advice to the parents, and so at home the parents can do it as well. Can you describe in more detail how it looks like, I mean, how you imply that? Yeah, I'll try. So, for example. So, it's a child with anorexia or with what is it. Maybe it's a child with, let's say, a brain tumor and brain tumor therapy, for example, medulloblastoma and [inaudible] chemotherapy and his appetite loss, already lost, let's say three kilograms, four kilograms from, he's already going down, and so we have to do a lot that the child does not lot lose weight more. One part of this is, for example, that we make the, we take Oxalis, we get it as a preparation. It's called Oxalis essence and with that we make a hot fluid, keep this hot fluid on a cotton towel, make this towel, wring the water out of the towel, wring the towel on the stomach, and close it with a woolen towel. Leave it for about 10, 15-minute till it gets cold. So, that's something that you can teach the parents. Yeah. I mean, we have different kinds of action. One action is the Oxalis or the plant itself. The other one is, what I do when I go to the child and say, "I want to do something good for you. I don't give you now chemotherapy. I give another external embrocation that you feel well. I know when I give chemotherapy you feel bad. I do something that you feel well." The third one is, most of the parents say, "What can we do?" They come to the hospital with the child. Give us same old child, like it, cure it. We sign, you are allowed to give chemotherapy, cure it. It's totally passive. They have no active role. In this kind of therapy, parents can get active and they enjoy that. So, there's a kind of activation gesture that parents can be provided with things that they can really do. I mean, it's not just to be in the being of anxiety. So, it is. But, they do something. Yeah. I wanted to ask you, it's quite unique. I mean, In many places in the world, there's more and more integrative oncology setting. Yeah. But, you're unique not just with the pediatric setting but with a hemato-oncology setting. Yeah. Which is quite rare, I mean, currently. Yeah, so it is. So, we talk a lot about integrative services, but if you look on this, it's not integrated. It's a specialized nurse for integrative therapy, and she comes, make a specialized things, and then she goes away. She's not to nurse and child who is on the wall all the day. That's really unique kind of integrative or that's what what we think is integrative. There are people in the world that practice integrative oncology and they feel considerably safe in the realm of solid tumors. Yeah. When they are challenged with hemato-oncology. I see. They feel that it's a sophisticated area. Yeah. So, what are your suggestions to integrative physicians or nurses that go into the hemato-oncology realm, I mean, what's the difference between that. In pediatric hemato-oncology, or in pediatric oncology, we deal about 30, 40 percent with hemato-oncological diseases, so it's our everyday life in pediatric oncology, I think, in contrast to adult oncology. We don't divide between solid tumors and hematological tumors because those, more or less, the same problem we have to solve. The main sources from which the disease may come and the main resources of the patient. We are applying for self-awareness, for self-care. So, don't make a difference between solid tumors and hemato-oncology. I know that quite what you can describe as lacunes in supportive care where the conventional supportive care is quite lacking like in thrombocytopenia or in neuropathy. It is not an optimal supportive convention one. Can you describe these areas where the supportive care is non-optimal or non-existing cancer-related fatigue that the anthroposophic care can fill the gaps somehow or provide other options? Maybe some gaps we can fill, yes, but we can't solve all problems in oncology as well as others. So, even we have patients with fatigue, we have patients with neuropathy, we have patients with loss of appetite, and things like that, but what we just talked about, the activation therapy. So, it includes movement, it includes body movement, but even spiritual movement. So, if you engage in art therapy for example, and you are painting a picture, a colorful picture, something in your soul will be activated, and you will be aware. You will awake. I'm quite sure and patients tell us about that, that you are not as fatigued as if you're only laying in bed having nausea and being tired and hoping chemotherapy will find its end. So, that's one thing. On the other hand, about mistletoe therapy, we are doing as well. I told you already about that. We know that quality of life during chemotherapy together with mistletoe therapy is in much studies shown to be quite better at quality of life means sleeping disorders, means fatigue, means or maybe even neuropathy and things like that. You talked about, you mentioned the concept of activation of the soul, and that's not typical to conventional oncologists, I would say, I mean we're talking about empowering the body or maybe the life forces somehow, but to activate this circuit can you elaborate a little bit more? What's the meaning in anthroposophy about will activation, the working with the spiritual realm of the child or with the parents? Yeah. So let's focus on the child first, not only parents, but if you have a child with for, example, a Ewing sarcoma, you can say, I have here the physical body who is sick. It's a tumor, it's a very aggressive tumor, but even the soul mustn't be sick and to spirit, if you take these three parts, body, soul, and spirit to take the whole person, can't ever be sick. So, you have a spiritual being of the child which is apparently healthy and from that, you can trust to and this healthy person itself can cure problems in soul and can help to cure problems in the physical body, we cure with chemotherapy plus radiation therapy with surgery. That's good that we have this opportunities from chemotherapy radiation therapy and surgery and sometimes it's enough most of them get a healthy without any additional treatment, but you're told about all the problems we still have in even in pediatric hematology and oncology and we can try to fill this gap with anthroposophy [inaudible]. We address our therapists to mostly to the soul and to the spiritual level and less to the body. So, do you see any connection between the use of herbs like mistletoe and the soul sphere. Do herbs like these have any connection with your motivation to work with these soul levels? I'm asking it particularly in a palliative care something, an advanced cancer and what is the role of herbs in this sense? Beyond the molecules, beyond their physical properties. I think we have to take a different look on it. On the one hand vertex mistletoe, for example, in palliative care we even do it with very high doses intravenously. So, there we have the molecule level and we take a lot of cramps and we were seeing that the effect will be on a physical level, but on the other hand, we have remedies in more diluted or potential way and these they addressed more to the spiritual law or introduced to the cellular level of the person, which shows a picture of how function could do or how function could work and how healing could work. It's not a molecule level, it's not any kind of pharmacological mechanism I can explain. It's more on, not physical level. So, in end of life setting, which is really dramatic with children, which herbs have a clinical role? I mean, with which herbs will work in this end of life setting? Yeah, yeah. So, some of them are told already, if you really talk about end of life or last days or couple of weeks of life, we don't do experimental surface like high-dose mistletoes. But we stimulate well-being of the patient. Giving him some drugs, some remedies to ameliorate symptoms like the same we talked about like nausea, insomnia, vomiting, constipation. Like that constipation for example, or it's diluted opium, opium diatrasic, it's a good remedy or even we do a lot with stearic oils, so that they smell which one, for example, lemon, or thyme or lavender to get calm. We sat together it was implicated with per-click massage with this oils. We tried together, they night rhythmic change. Most of them, they don't know it's morning, it's evening, it's midnight. Though a lot of nursing practitioners, trying to divide the day in morning with afternoon and not actually 24 hours. For example, giving three or four main meals. Most of them, they don't have appetite, but just to smell or to try a little bit. But not every five minutes, oh, you want this, you want this, you want this or if you want that, I give you that, and so we tried to bring calmness in it and to bring rhythmic elements in daily life. Though it's not, it's even remedies you're told about, but it's a lot of them they giving structure to daily life, with the end of life. So, is there any role, I mean those in transition usually between quality of life impulse to quality of dying? Do you find any use of specific herbs or gestures in this difficult process of? It's at least, one specific remedy be used in this process, it's called olibarnum com. It's a mixture of gold, myrrh, and the third is vidal, I don't know if expression what are the three kings brought to rest when he was born. I don't know the expression sorry for, Vidal and this special composition is remedy, which helps the patient through our final set, to make a decision to die or make the decision to live long. To live for a longer time. From a very anthroposophic viewpoint, dying is not the end of life, it's the end of physical life on the Earth, but dying is going over a step in another kind of being, and so it's not the moment of dying is end of existence of this individual. It's end of physical existence, but spiritual existence goes over this way for a long time. So, you use it as part of what we call pentagram movement around a patient with specific ways to use this herbal remedy. They say that these remedies like an entrance or like a gesture that the child can take? Yeah, so it is. For the afterlife or? Another remedy we use in this situation is fero fulum. Fero fulum is a plant, we give it for if patients are very, let's say, they can't come through to a calm. They are very active they can't sleep. So use this remedy intravenously as five percent at first or orally as 50 percent and it's working quite well.