Hi, I'm Jun Mao. I'm the Chief of Integrative Medicine Service at the Memorial Sloan Kettering Cancer Center, in New York City. I'm also the current president for the Society for integrative oncology, an international inter-professional society, dedicated to advancing the field of integrative oncology. We have been around for about 14 years. So, I'm very excited to be here. Thank you very much and can you elaborate a little more, about your training in integrative oncology? So, I was trained in family medicine, board certified internal medicine, as well as in acupuncture. So, I practice both conventional medicine as well as acupuncture. In the early part of my career, also received the additional training in palliative care. That's how I got into the world of supportive care in cancer and cancer supportive care. Ultimately, I developed research career in clinical and translational research, in the area of integrative medicine for cancer survivors. That's what has lead me to the Memorial Sloan Kettering Cancer Center. Well, I would like to understand a little bit more on your perspective, regarding the use of herbal medicine in the setting of palliative care or supportive care. I mean, what are the pros and cons, you got in the integration of herbal medicine, during chemotherapy or during palliative care? That's a really good question. In the United States, the use of herbal medicine among cancer patients or survivors is about 20 percent, above any kind of what we consider a biologically active ingredients. That number is higher in patient with advanced disease, with younger patients and patients from higher socio-economic classes. But, if you look at in cultures, that herbal medicine has been part of their tradition. For example, I came from China originally, in Chinese cancer patients, the use of herbal medicine is as high as 80 percent or greater. So, in the context of cancer care, the use of herbal medicine can have both benefits and potential harms. The benefits such as, often those herbs are used in it's original cultural context, give people a family or a sense of control and some of the herbs may have both- although may not have adequate research data but have a lot of empirical, historical use. Whether it's ginger for a nausea, Low dose ginseng for cancer-related fatigue, curcumin for boosting immune system, various mushroom species in both Asian and European countries to help immune support and supporting overall sense of well being. Those although, not much research but, there's a lot empirical support to it. But, the potential danger of using herbal medicine during active treatment such as chemotherapy is herbal drug interventions. In general, I'm not opposed to using herbals, in terms or using it in it's natural form. But, when you're using a highly concentrated supplement form as, the herbal drug interactions of adverse events of herbs, are often not well understood. So, the use of herbal medicine in cancer, it's not like a yes and no, it has to be weighed by the risk and versus benefit. In general, we consider, for a patient with highly curable disease, were existing conventional cancer treatments are known, if there's potential herbal drug interactions, we advise patients to stay away from herbs, at least during the active chemotherapy or radiotherapy treatment area time. However, in circumstances where there is no conventional cure or is purely for palliative care intend, the use of herbs traditionally monitored by physicians for organ toxicities, as well as potential benefit, is probably has more benefit over the harm. So, how does it look like practically, in Sloan Kettering, in the integrative oncology program. When a patient come, is he referred from the oncologists or just come to your consultation by his own initiative? So, we are part of the department medicine. So, we're one of the many sub-specialty area of medicine within the medicine providing patients, as part of comprehensive conventional cancer care. So, we get a lot of referrals from our fellow oncologists, whose patients either are on multiple types of herbs, or dietary supplements, or they're interested in initiating those in the combat of cancer then, they are referred to us. So, we evaluate patients, do a comprehensive evaluation, for their both herbal use, their symptom toxicities, their goal of care as well as their lifestyle factors, So, we work with the patients to develop a comprehensive plan, that often may involve herbs or may ask patients to delay herbs until a safer time. So, I understand that usually, you receive a referral from the oncologist? Yes. Do you receive referrals from other health care practitioners, like nurses or family physicians. Or is it usually through the oncologist? Our majority of referrals come from oncologists. Sorry for saying that in that term. At MSK, we have a very collaborative working environment between oncologists and nurses. So, they really function as a unit, a team. So, it's an oncology health care providers. Yes. I think, primary care are a little bit more outside of that care delivery and often in a very active treatment state is the oncology team, leading that process with the primary care probably serving in a supportive role just like us. But certainly, in cancer survivor-ship settings or palliative care, when conventional cancer treatment is no longer rendered. I think primary care play a huge role. In general, we do not get a lot of referrals from primary care, just because we are located, we are already getting more supplies over demand. It's not uncommon, we have five weeks, six weeks, seven weeks, we are less, despite we have four physicians. So, these referrals from healthcare practitioners, oncology healthcare practitioners. Do they include sometimes questions about the herbal use, or what are the indications for referral? Absolutely, a lot of the challenges is in conventional oncology training, or medical training in general. There's very little about herbs. So, oncologists, at least most of them, from my perspective at MSK, are not necessarily, completely blanket against herbs, they are worried about herbs. So, they want to do the best for their patients so, they refer to us, who have expertise. Really carefully evaluate benefits and harms, in the context of their conventional cancer treatment and then make appropriate recommendations. Follow up as clear. So following the referral, I understand that there is a kind of intake of integrative physician who sits with the patient and explore patient expectations, concerns, quality of life issues. This is how it works, I mean there is an intake of integrative physician. So we have our initial consultation were we spend often an hour with the patients, really get detailed history both conventional medical issue, but it is good we work in the same health care systems. We know a lot of their conventional cancer treatments or the plan of the treatment. So we don't need to spend extremely, if I'm seeing a patient from outside a setting I need to get a lot of that history, but that often I read before the patient even walk into the door. So we focus a lot of time on understanding. We always start with, why are you here? How can I help you the most? Some patients are really coming to see us to talk about herbs, but we also have a lot of patients just have terrible fatigue, or terrible neuropathy. Their current management is not inadequate, as is we our group have done a lot of research in the area of acupuncture, massage, music therapy, and we also have services like exercise fitness, dance multi-sensory therapy. So, a lot of patients are in a lot of mind-body therapies like yoga, mind fitness, stress management, Tai Chi, and martial arts and Chi kung. So people are very interested, are there additional ways to help them cope with experience living with cancer, both the psychological aspect whether it's the fear, uncertainty, stress, or the physical aspect sort of fatigue, lack of physical function, strength, flexibility so on and so forth. So at the end of the intake, you formalize or you structure a treatment plan? Yes. I mean the key thing is patients often come to see a doctor don't have the specific things written on their forehead, I'm here just for a thing, and they often want a variety of advises. I think the key thing is to develop a plan on how patients are prioritized. Cancer treatments nowadays in the West, and as well as in the most of the countries are very complex, require a lot of the treatments whether it's infusions, radiotherapy, and now with targeted therapy, immunotherapy just a lot going on. So, and then the patients say, "Oh, I want to do good diet, I want to try herbs, I want to do stress manage, I want to exercise, I want to work on my sleep." In my experience working in clinical research as well as behavioral change, I was involved in large obesity trials, a patient who want to do everything, you don't prioritize, they end up doing nothing. Like any therapies whether is herbs or physical activities or sleep, hygiene improvement, all require commitment from the patient and time energy. So the important role of our physicians are to help people understand what is their party and what therapy is the most evidence-based, and potentially, it can be most helpful. Part is that work with one or two, I always will say, "No more than three things at once to getting started and then monitor as we go." Certainly, that plan has to really get patients input understanding what's a patient's party. So how do you actually tailor the treatment program to each patient? I understand that there is an individual impulse as well in considering which patients can benefit from herbs or from other modalities. I mean what are the main considerations if to suggest, if to include herbs in the treatment program or not, is it related to previous experience with herbs or expectations to use herbs or nutrition? I think there are four major areas. One is what patients bring to the table. Sometimes you have patients bringing a whole bag of like 20-30 herbs in front of you. I find those contacts just say, "Don't use. Typically, don't go very well." Often, patients feel disrespective and alienated, and my gut feeling is they're going to go back to use the same way they want. Often, the easiest thing for a doctor to say, "Don't use it, trash it," but that's not going to help the patient, and our job is here to help the patient. The second thing is I think the most important thing is safety. I often really, in this circumstance, we have this great website called About Herbs to really discuss herbal drugs to interactions. So my biggest job is to really look at is our potential, drug herbal interactions with these patients' chemo regimen. If there is, it is, I typically really select the herbs that can be potentially problematic in this setting to say for this set of herbs maybe, to just take a break, or at least don't use it within the three, four days of the chemo infusion to make sure to allow to decrease the drug herbal interactions. The third thing I think is really based on some empirical evidence. There are some herbs, there's a lot of traditional cultural historical use, with some sort of benefits for specific symptoms. If the symptoms are more aligned with this, you can potentially make sort of a careful recommendations, or for example, it is not uncommon when we see patients with really extreme form of vitamin D deficiency, like vitamin D level four. So in that context, providing some vitamin D supplementation I don't see a problem with that. Last but not least, I think cost is also issue. People often forget herbs are not cheap, and it is not common in my clinic a patient will bring the monarch herbal cost in the realms of hundreds if not thousands of dollars a month. So often, the herbs are not really the patient's want to do, it's more of the family and friends. Mr. so and so, you have cancer. I'm here to help. So, I don't know anything else, I'm just buying herbs for you wanting to help. So, the patients, the family and friends are really well intentioned, but the problem is that then eventually after that gift, that's patients' responsibility to pay for it, and cancer care is very expensive. A lot of time, patient don't necessarily want to take all those herbs. You'll be surprised, at least in the US, and they actually need a physician's input to say, it is okay if you don't feel direct benefit from taking this 10-12 supplements. You would rather eat food, maybe it is okay not to take all of the herbs and maybe optimising nutrition and food as a source of support. I think those are the, I will say, the key ingredients we cover in consultation. Now, I wanted to ask you, regarding a potential synergy between herbal medicine and other Complementary Integrative Medicine modalities in the setting that we're talking about, about supportive cancer care. Do you see any reason, any potential synergy between acupuncture, for example, and herbal medicine or mind-body therapies? How do you perceive, maybe from the point of view of, from the clinical point of view, when you design the treatment program or when you monitor the results, how would you see that interaction between different CIM modalities? I think the way I see is if there's synergy, also there could be interactions. So, I think this as area really requires a lot of research to fully understand in what context synergy maybe better. I was involved in a large call on integrating acupuncture in the same setting as physical therapy. We actually found no synergy at all in that setting. So, often I think it just wishful thinking, you pile all the things together. I wouldn't feel like its necessarily the best way especially with cancer patients. I think our wisdom in conventional cancer care often indicating there are circumstances less is more. Even if we look at surgery for women with breast cancer, that over time has really went from very barbaric radical mastectomy now to lumpectomy with radiation. So, I'm more of a believer in understanding what is the potentially most beneficial aspect of the care for patient to prioritize that, rather than combining too many things. At least in my clinical setting, I find patients are very overwhelmed. When you have cancer, you also want to live a life. You want to have some time with your family because the time may not be a lot. I think if the patient is spending all their time getting acupuncture massage, doing mind and body, literally that patient will have no time to live. So, I think the way I would approach is understand what patient wants the most especially when you're dealing with patients with advanced disease, the time may be limited. The second is to understand what therapy may have the most clear evidence of benefit and least potential for harm and also is within the financial capabilities of the patient to really align that. And then develop the treatment prioritized down to one or two things to start. If patient wants to do more than patients or more, welcome to do more. But the last thing you want a patient, if she does acupuncture, she just try it once. She does mind-body, she just try it once or twice. She does yoga, she'll try. Because lot of therapies, if you don't take cumulative at least for eight to ten treatments, at least that's what the researches show, it doesn't really show any benefit. So, it's much more important to try one thing does help of course rather than try five things only does one or two times. I wanted to ask you regarding, can you just characterize your team in Sloan Kettering? How many physicians are there and practitioners and the variety of modalities that you can offer? At Memorial Sloan Kettering Cancer Center, we have probably one of the largest integrative medicine service, at least in the United States. We have four physicians, and our model has evolved over the time. I think our current model is more of a physician-driven Integrative Medicine model. Before it's like patients just spontaneously come for various things. They put the pieces together themselves. Yeah, yoga here and there. Yeah, and now we actually will recommend they come to see a physician and we help them develop a plan. And then, we have a team of very highly skilled practitioners in acupuncture, massage, mind-body, in the mind-body area we offer yoga, Tai Chi, Qigong and mindfulness stress management or meditation, and we also have fitness instructors. And in the inpatient setting for pediatric cancer patients, we also have dance therapies, I think a lot of girls really liked that. And we also have martial arts therapy that a lot of more older kids, teenager or some boys, really like those kind of outlet. We have about two-thirds of our care provided in the outpatient setting. About a third, 8,000 or so visits are in the inpatient setting are completely made free to our patients. It's free? Our inpatient care is completely free and supported by the hospital. Wow. Yeah. And that's 8,000 visits a year? Yeah. Wow. We have both a really comprehensive program for adult patients as well for pediatric patients. So, how many practitioners are on board, in your team besides the four physicians? We have a combination, then we have administrative staff, how to schedule appointments, how to make sure the clinic runs smoothly. All, including our part-time folks, we are close to 60 staff and faculty. Wow. Yeah. It's a big service and we are also located in multiple sites in Manhattan, as well as we're expanding to the regional facilities in New York, New Jersey that really try to bring Integrative Medicine to where patient lives. Because for patients to expect them to get into Manhattan to do acupuncture weekly when they live in New Jersey, it is impractical and too expensive and spent too much time for your patients.