I would like to introduce Professor Moshe Frenkel, leading integrative physician in the realm of integrative oncology, a family physician, and the physician that was the medical physician in MD Anderson in Texas. I would like to ask you several questions about the topics of integrative oncology. The first one is a definition, question regarding definition of how do you perceive the difference between alternative and integrative medicine in the realm of oncology, of course? In the old times, we used to look at alternative as something that was coming instead of. As we progressed, we said, ''Let's talk about complementary.'' Anything that can complement the deficiencies that we have in conventional medicine, and now we're talking about, "Let's look at the best of both worlds and try to integrate both of them together." The best from conventional medicine, the best from complementary or whatever natural medicine that was described in the past and tried to combine them together so patients will benefit from it. So where does the traditional medicines stands in between alternative, complementary, integrative, and maybe specifically, traditional or herbal medicine? Well, it goes according to the culture that people are coming from. People are coming from different cultures, and they bring their background of what their grandmother was utilizing, what was accepted in the community in the old times and bringing to the new tradition. So, nowadays, it's changing because what was traditional medicine in the past is slowly, slowly is disappearing. More and more people are using conventional medicine, and what we are trying to see is how we can utilize the old times, and maybe we can integrate it into the new times. We're talking a lot during the last years regarding the role of doctor-patient communication and communication with all health care providers in this integrative setting. So, I would like to ask you, how does it look like? What's the meaning of integration, of integrity of concepts within the dialogue between patients and their care providers? I think the most critical important point here is that we have to listen to the patient. What is the patient bringing? We have to go with what the patient desires, wants, what they're looking for, and then see how we can go along with their desires, their wants, their needs, and trying to address that. So, we're looking more at not just following a very algorithm-type of medicine, but trying to be more in tune with what is going on with the patient. So, this is what we are looking at, what we feel is patient-centered care, where the patient is in the center, and we're trying to address their needs according to what they're looking for and seeing if some of the things that they are looking in integrative medicine, traditional medicine, we can integrate into their realm of their care. But how you create an atmosphere that is more open or non-judgmental on one hand, and on the other hand, oriented to science, to concepts of effectiveness, of safety, how do you combine them? It's very tricky. First of all, you have to understand that the first and a very important part is, actually, you have to listen to the patients. You have to see what their needs are, and then from there, you start building some kind of a plan that actually addresses their specific needs and what they're looking for in what they look in the interactions that they come for. Sometimes we are so deep into these integrative concepts. Can you just suggest physicians who have no integrity of training in their background? How to promote this open non-judgmental yet scientific approach, just to oncologist? What are the tips that you can provide here or suggest to oncologists or to other health care practitioners who work in the oncology realm, regarding the way to communicate openly with patients? I think that if we take a very simple thing is just the first five minutes, don't say anything. Just listen to what the patient is bringing in. They're usually in the first five minutes. They would talk about their expectations from the specific interaction that they came to. Then you can explore a little bit more into the specifics of the needs that they bring up and try to figure out how you can be helpful in what they're looking for. So, I think this is the most critical part. If we don't hear what their expectations and their needs are, then we can come up with a very organized plan that we can call it integrative, but it doesn't actually fall into what the patient really is looking for. Citing a few examples, it's like I feel that when we talk about integrative medicine in oncology, we should probably cover five things: nutrition, nutritional supplements, lifestyle changes, complementary therapies that they can actually use to improve their quality of life, and then the last thing is, of course, discussing the issue of mind-body connection, spiritual. In the beginning, I was very trying to be covering all bases. Nutrition, and supplements, and being full integrative practitioner. But as I went along, I noticed that sometimes patients are looking for specific things. Some looking for some nutritional advice, very specific nutritional advice. Some are just coming with their list of supplements that they are looking for some kind of directions what to choose, how to choose, what's the best one that is has more possibilities and less interactions with the treatments that they're doing. Some are looking just for tell me what I can do to myself as far as improving my quality of life just by improving lifestyle, doing lifestyle changes. What kind of complementary therapist I can utilize? Sometimes people come in just with a question, a simple question, is acupuncture works for this specific issue that I'm looking for? At hot flashes, is acupuncture working for that? When I give them just that specific answer, they feel satisfied. Sometimes it's the other way around. They want to hear everything that you can actually give them. So, it's really, you have to sit with the patient and see what their expectations are, and according to that expectations, then you give them the advice. So, it's not a textbook, you have to do this, and this is what's been done. You know Marsha we tend to be very individualistic in the way we approach patients in the West, but there are some considerable cross-cultural aspects when you see as an integrative physician, patients in the States or here in the Middle East. As a medical director, you used to be a medical director in MD Anderson, and now you're an integrative medical director in [inaudible] in Mayo Hospital. Can you compare patients in both areas, both regions in terms of expectations of the way you weave the treatment plan according to that integrative concepts? Sure. In the MD Anderson, there was the patients who were bringing, their expectations was to hear a lot about supplements, nutritional supplements. Including herbs. Including herbs. Including medicinal herbs. They used to come in with sacks of boxes of things trying to figure out what they should use and how much they should use and what more can I add to this list? In Israel, it's not the same. They don't come with suitcases of supplements. They actually come with specific things, they would like to hear about nutrition, to definitely open to hearing about lifestyle changes, and mostly about other complementary therapist that they can utilize during the treatment to reduce the side effects of treatment. This is I see more the emphasis is a little bit different. When you see people that are coming not, you would say from this is the Jewish population. But when you talk about the Arab population, they're looking more into herbal medicine. They would like to hear if the herbal doctor in their community that suggested for them to use specific plans, is this is something that they should do or not, and what do I think about those specific herbs? So, it's really different when you talk about the Russian community. Russian immigrants that are coming. They are coming also with a lot of questions about supplements, nutritional supplements, and they like to ask a lot of questions about homeopathy. European people coming from Europe of German descent or things like that, homeopathy supplements, herbal, Western herbal medicines are definitely on the board. So, it's really depends which patient is coming to you, their expectations might be different as far as the advice that they're looking for. So, what is your approach towards herbal treatment during chemotherapy or concomitant with biological treatments and so on or what do you advise patients. Well, in the United States when I used to sit with patients, I used to put all the boxes on the table, and I tried to divide it into three piles. One that they should not use. Definitely should not use because there are some studies that there is some toxicity related to the use of those specific ones. On the other side, a smaller number of supplements or herbs that there may be some suggestion that there might be some benefit in the use and then very important thing in that pile, is that they don't carry toxicity. There is no problem as far as toxicity, and then you have other supplements that are in the middle that basically, we don't know. Big question mark. Nothing is written about them, and if they take it, you don't know if it's helpful or not helpful, and you have to see how much the patient is putting into a specific supplements. If you really, really strongly feels that this question is something that is worthwhile. I don't stand against him and saying do not use, okay? Because I think that there is some kind of an element of, we call it placebo, we call it other things that maybe when the patient really believes in something that is not toxic, maybe can help him. So, the things that are in the middle is a big question mark, it's a gray area. I try to push patient to think more about the ones that are more on the safe side, and that might have some beneficial effect because patients come in, they want to come in then take something by mouth. They feel that there is this magic thing in taking it by mouth. So, you cannot say do not use anything. Because if you tell them, do not use anything, they're are not going to come to you anymore. They won't tell you that they use those. They wouldn't tell you that they use those things. They wouldn't participate in your plan of action. You have to address this specific needs that they have, and if you just come in with a complete negative approach to supplements, you're going to lose the patients. Do you find that it's more significant in communities where there's high affinity to herbal medicine to traditional medicine like the Arab community in Israel or the Mexican maybe community in the states, that it's part of the health belief model. I mean in a collective perspective, it's part of what they believe, part of their identity, cultural identity? Definitely. In Houston, you had Hispanic population. You have people coming from India, people coming from Korea, people coming from China. People came from all over. You had to listen to what they're saying, and see where they're coming from, and their cultural background. So, you can address their actual needs in a way that they don't hurt themselves, and they actually participate and go along with the plan of action that you go with. So, it's crucial to understand the cultural background of the patient that comes to you, and what does that mean that Arabs have their tendency to use more of their local herbs? People that are coming from India, they tend to use more Ayurvedic medicine. They use specific plants that are connected to our Ayurvedic medicine. They are very much open to homeopathy. So, you have to address the differences between the different communities, the different cultures that those patients are coming from, and be humble. We don't know all. We just have to go with what the patient is coming with and trying to go with him to move on and helping the best we can. But beside being a nonjudgmental listener, I assume that you're proactive as well in terms of your giving that advice, use that herb and that herb, I mean you initiate that is well, if I understand correctly. It's not just that you provide in consultation about what the patient takes, but you initiate that as well? I think so because when you coming, I have a list of common herbs that I think that they are safe and there is some background information that might be beneficial. Not great evidence as you would like to see in randomized controlled trials, but there is something there, and that they are safe to use. Sometimes they are used as herbs, sometimes they are used as spices, and they are safe to use. I try to direct patients to use that. But, patients that are coming from Arabic tradition, their tendency to use specific herbs that are coming from the Middle Eastern area are going to be very high. If you going with them and suggest to them some of those specific herbs that belong to that area, they will really appreciate your advice. When you're talking about people that are coming from India and they are looking, and you give them some advice about ayurvedic herbs that are safe to use, that there is no major toxicities to them, they would really appreciate that you are in tuned with their background, with their culture, with what they do. So, it's really depends on the patient that comes to you and it's very important to address who's coming and build the plan according to the patient that is coming to you. So, there's no same plan to everybody that comes with breast cancer, has to take all this. This is the plan. This is the actual integrative medicine approach to breast cancer. You have to do some tweaks in the plan. So, it's more complicated than what other people are looking from the outside into integrative oncology. So, I would like to ask you regarding the heart of the integrative medicine practice, the moment that you tailor a patient centered treatment, patient tailored approach, how do you actually tailor that? Let's assume that you have a one hour of consultation time, and that at first, you ask the patient about one's expectations and past experience. You evaluate the quality of life through different questionnaires. But when the time comes, after 30 minutes or so, and you are just starting the design of the integrative treatment, how do you do that? How do you choose herbs, or supplements, or acupuncture? Is it a patient tailored approach? Is it something that you need to consider the cancer type, or the chemotherapy type as well, or whichever other considerations? How do you do that actually? First of all, I think you are right. The first half an hour, you're trying to gather information from the patient. You're trying to figure out what type of disease he has, what kind of complexities he had during this trajectory. Then, trying to see if what type of experience he had with complementary medicine, and was it good? Was it bad? Is it something that they would like to try or they are very close to trying it? Look what expectations they have from this specific visit that they came to you. This is very crucial to the way that I built the plan of action. Of course, if somebody comes in with, "I would like to have everything." Which sometimes they do. "Give me everything I can do." Then I go through the actual plan, which is nutrition and I'm looking for things that are specific. If the patient comes in with breast cancer, I will try to look for specific things that are nutrition, nutrition that is based on evidence on the use, or prevention, or reducing risk of breast cancer that they can utilize effectively. Practical information that they can actually use the following day. Then, if they have the interest, talk about maybe three or four nutritional supplements that they can utilize and they have benefit in their use. I'm very specific and I tell them exact dosage, and side effects, and what interactions they're supposed to have. Then, discuss the issue of lifestyle changes sleep, exercise, things that we already have enough evidence to actually suggest to the patient to utilize. Complementary therapies that can be utilized. Mostly, I'm looking if they have specific symptoms that we can address those symptoms and reduce. If they're doing chemotherapy, if they're suffer from specific symptoms. Most of the complementary therapies that we have under our hands acupuncture, reflexology, and things like that are very helpful in utilizing it with these type of patients. Of course, addressing the issue of mind-body is extremely important and discussing with them about reducing stress, breathing techniques and things like that. So, this one hour becomes a very short hour but you're trying to, within this one hour, trying to give them something in each of these five domains, so they can come up with something that they can actually utilize the following day. But, is it a process? The moment that you define the treatment goals and design the treatment plan accordingly. Is it a co-design with the patient or it's something that comes from you? Is it a shared decision-making process? How does it look like? It's a dance or is it something that is more hierarchically? It's completely, it's a dance. If I come in and I believe that nutrition can be helpful, and the patient, I tell him, "Let's talk about nutrition? The patient tells me, "I'm not going to change any nutrition. I know that I'm not eating the best, but." I don't go with them on nutrition because, if I sit down and trying to convince him for half an hour the value of nutrition, he's going to go tomorrow and. But, if he puts the main issues on, "I want you to give me this specific supplements. " Then I go with him and talk to him about those specific supplements. I mention the other things as well, but at that point in his trajectory, you have to understand that you have to go with him because this is a process. He might hear a little bit in two weeks, or three weeks, or four weeks, or two months, or three months. Then, he'll come back with the issue of, "We didn't touch nutrition that much, how can I do something with nutrition?" So, you have to go with the patient at their time. Where they are at that specific point of time and trying to built with them. It's a dance as you mentioned. It's a dance. You're trying to figure out if this is the right thing with them and then come up with the plan that they feel comfortable with. So, it's a little bit complex. You know Moshe, I think that we teach together, complementary medicine and later on integrative medicine from 1999 together and. It's almost 20 years. Yeah, and as time progressed, we have become more mainstream in a sense. So, my next question is about the debated area of homeopathy. Moshe Frenkel, of all people, can you explain me what homeopathy is and specifically in the realm of integrative oncology. Okay. Homeopathy is basically, it's a method of treatment that was basically developed in Europe 200 years ago. The main thing is utilizing very diluted substances that actually can affect the body, the mind. Usually, it's natural substances and has a background of a few, the 200 years that I mentioned. In oncology, I had the feeling that there's no role for homeopathy in oncology. I felt like it might help in functional situations such as inflammatory bowel syndrome, or irritable bowel syndrome, or headaches, migraines. Stress and things like that, but they didn't think that it would have any effect in oncology. When I got to MD Anderson, I had the luxury of sitting with patients for two hours and hearing what their main expectations, what their main things are, what their needs are, I start hearing a lot of stories that none of the physicians in that institute heard. One of the things that I started hearing is about an underground movement with brain tumor patients that they actually use homeopathy for brain tumors, and it came out as a real surprise for me because they had some kind of a website that they used to transfer from one patient to another patient. It was like an underground of patients. Doctors didn't know anything about it. Non-disclosure. Non-disclosure. Nobody knew about it, only the patients. They sit down in the waiting room and they tell him, "What do you do?" "I went to this site, I went to that site. I used this, I went there." So, it was very interesting, and I start looking into the websites that patients were utilizing. One of those websites were a website that dealt with homeopathic remedies used in a homeopathic study done in MD Anderson. I was really surprised. Somebody did an MD Anderson study on brain tumor cells here, and I invited the researcher that actually did the study, and it was a molecular biologist, a completely traditional molecular biologist and he told me, "Listen, there is something strange with homeopathic remedies. I don't know, but something is there. This is what I published. This is what I believe in." Okay, and he says, "I want you to meet homeopathic physicians from India that is going to come here in two weeks where he's going to tell you about his experience." Says, "Oh, okay." So, I met this homeopathic physician. This homeopathic physician says, "What you see is nothing to what I have in Calcutta, in India. Come and visit my practice and you'll see something amazing." I was scratching my head and I decided that I'm going to go there. I went there and to my surprise, people in India, they get diagnosed with cancer, but then they can't afford to actually pay for treatments, chemotherapy, radiation, they can't afford to do that. There is no health care plan that actually is utilized there. They come to this Dr. Banerjee. Each day, there is a line of two miles of patients waiting to get into his clinic. He has about 15 other doctors working with him. The clinic sees about 1,000 patients a day. Out of that, about 200 to 300 patients are cancer patients. Him and his son see all the cancer patients. So, I was sitting with him for two weeks from morning till night and I saw there were things that were completely strange. I didn't think that they exist. He showed me x-rays and patients, and I was really amazed. He showed me a kid with osteosarcoma that actually, you don't have to do a radiology and you see how the tumor is in the bone in a regular x-ray and then you see that eight months later that there's no tumor there, same patient. You have the histology report, not the best, but actually there is a histology report and you scratch your head and you say, "What's going on?" You actually see the kid and you interview the father. The father is telling you, "Listen, I didn't want him to have his leg cut. I wanted him to play soccer. I couldn't afford to do that." "What did you use?" "Just the remedies that this Banerjee gave me." I was really amazed with that. When I went back, I took some of the remedies that he used for breast cancer. I managed to convince the people in MD Anderson to actually do a study on those remedies. This is how it started. We basically tested homeopathic remedies that he specifically used for breast cancer and compare it to regular breast cancer cells and see what happens when you actually combine it with homeopathic remedies compared to chemotherapy. In vitro study with cell cultures? In vitro study, everything was. We had to make sure that those remedies didn't carry chemotherapy in them. So, we actually tested them that there's no chemotherapy there inside the bottles. As a matter of fact, we ordered from a completely different company, the same remedies. We actually tested them one side-by-side and it was an interesting revelation to see that there was some kind of effect which we didn't expect it to happen and that the effect was very similar to chemotherapy. You're talking about ultramolecular dilution? Ultramolecular dilution. I mean, C30. All those remedies were C30 or 200C. Basically, it's diluted to, none of the original material is in there. Ten in the power of 60 or? Ten in the power of 60 or more. With no active molecules? No active molecules. Beyond Avogadro number. It was funny because when we actually finished the study and this was the findings, my colleague says, "I don't believe this is the right thing." It's like you're checking it in the Indian laboratory here in MD Anderson and there are a little bit more in favor of them." [inaudible] is like, "Let's move it to the Chinese lab." They actually did it again and we got the same results. Then it was a study like this being published in the international literature, there's no way that this is going to be published and it was published. The day I left MD Anderson, it was published. It caused a major reaction, but that was the end of it because we're trying to do a clinical trial right now in May with those remedies with patients that have advanced breast cancer, but it's a slow process. So this is as to homeopathy. Moshe, I would like to ask you if you have any tips to an oncologist, or nurse, or health care provider, that is about to open, to launch an integrative oncology project somewhere in the Middle East, or in the Mediterranean, or Asia, and what's the ABC? Somewhere in the world. Somewhere in the world. Well, what's the ABC, the tips that you have in order to facilitate a successful project inside an integrative service or institution? It's very interesting because I had the experience of two different projects or two different centers. One center that is very high influential type of a cancer center with no problem with funding and large support staff, and then the other experiences that you are in a center, that basically there is no funding at all, and you have to actually survive in that kind of center, and make that activity happen, and you're trying to figure out, how do you go as far as building a new place or somebody that actually wants to come with the specific advice. What do you do? How do you, I can say that there is a few things that actually are very similar. Few things, not a whole lot, but a few things. First of all, when you come to an oncology center, you have to learn the environment that you're working in, and you don't come up with flags, "I'm doing integrative medicine, and this is what I'm going to do." You'd coming up with just have to observe the specific center that you're going to be working in. Learn the people that are actually working there, and see how you can utilize a plan that is a win-win plan, that everybody can benefit from it. Coming up from outside with a very organized plan to a new place is not always beneficial or going to be successful. So, the first thing is you have to learn the place. When I came to MD Anderson I told them that I want to learn four months. I just want to learn. Don't expect me to open anything. I just want to learn the culture of the institution. When I came to Mail, I sat down for four months, and I didn't see even one patient. I just wanted to see what they're doing. What's the atmosphere in the actual institution? How it's moving. The second part is you have to know what type of treatments you're going to utilize, and I think there is a few things that are essential to have in an integrative oncology. One is something that relates to nutrition, and then the second part is complementary therapies. The minimum that you have is acupuncture and some kind of a body or a touch therapy that you can actually utilize. The third part is to have something that relates to the mind, the spirit, and if you can combine all three in those practitioners, that is the best. Practitioners not always are coming with that kind of a feeling. They are coming with, they have to do acupuncture, but they have to do reflexology, and you have to change them a little bit, and say, "You're an integrative practitioner that actually integrates a few modalities in the care that you provide to the patients." The third part is actually, how do you interact with the people that are surrounding you, the nurses, the secretaries, the physicians? The easiest is to actually work with the nurses. The nurses are always the first one to be open and refer patients to you. The physician, that takes them time, and after they see a few patients that it actually worked, then they start referring to you, but the nurses is the main element that you have to connect to. So, I think those are the three main things as a starting. Just as a start. Okay. Great. It's a very important advice, and I share what you say. You know we're sitting in the room where I started here in the same four months that you recommended me 10 years ago to do that. Just sit here and not treat even one patient, just to observe what happens. I would like to ask you in the same spirit, what happens to those health care providers, if you can just contemplate it, the healthcare providers, the nurses, the physicians, the psycho-oncologists, maybe the family physicians, the surgeons, and so on. What happens when they are exposed to integrative medicine in terms of, is there any change that happens? Do you think that integrative medicine can affect not only patients, but healthcare providers as well? I definitely think so. Because what happens is, first the nurses, they hear what the patient is experiencing, and if there is a positive experience, and there's another positive experience, and then there is another positive experience, then they start referring patients. Maybe we don't know what to do with this. Maybe you should see those complementary therapies. Maybe they can help you, and they come back and say, "Yeah, what a great suggestion. It really helped me." Then the transformation starts is when that specific nurse goes to that specific practitioner and says, "You know, I have this headache, do you think you can really help me?" This is how it moves on, and then after the nurses have that kind of experience, then the doctors quietly pulls the practitioner and says, "Close the door. Close the door." What? Do you think you can do something with back pain or with something personal that they have? When they actually see this as a positive experience, then they start referring patients. It's a slow process. People have to be humble. Don't push it on the physician. Don't push it on the nurses. It will come from them. It's a slow process. Nouwen talked about the wounded healer, and we're talking today about compassion fatigue, about burnout. Do you think there is any role to integrative medicine in alleviating this burnout and compassion fatigue? I mean, is there any inner process of growth that can happen, professional growth, post-traumatic professional growth that could be facilitated by integrative atmosphere? I think that nurses in oncology and physician in oncology are going through a major stress because they have to keep up, and they see so much suffering, and they still have to protect themselves from it. It's a major toll on their inner side, and we have a project now that we actually take nurses and actually treat them with integrative medicine in the department itself. Just because we start noticing that the stress, and the anxiety, and the compassion fatigue that is happening is so high, and when you're actually providing that kind of care, they really appreciate it. They feel like, aah. It gives them some breathing space, so this is something very interesting that we're actually doing right now with the nurses that we have in oncology department. Another question regarding one of the main topics of your research, about exceptional patients and about cancer survivors, so to say, as the American call them. What is really exceptional patient? Do you think that there is any connection between patients beliefs, practice, in our case, maybe affinity to traditional herbal medicine and to be exceptional in a way? This is something that, I think that patients when they know there's other patients that actually went through the same trajectory that they had and they saw that they actually survived brings them a lot of hope. This is something I saw when I start speaking to patients that are basically in a very close to terminal situation, or they've very bad prognosis. When you talk to them about, the studies shows that in every diagnosis there is, even the worst type of cancer, there is 2 percent that actually survive. Let's see if those 2 percent, what we can learn from them. So, this is the study that I've been doing for the past 10 years, looking for patients that actually we feel that their prognosis is dismal. They actually completely surprised all the physicians involved, and the doctor looks at this patient, scratches his head and says, ''I don't know how this patient survived.'' So, we went and interviewed quite a few number of patients. The interesting things that we found from all those interviews is, first of all, all those patients were very active in their care. They actually chose their physicians. They actually chose their oncology plan. They actually changed it with their physician. It was a very active type of involvement. The second part, which was very interesting was that those patients had a very interesting trajectory. They had the bad doctor. They had experience with a bad doctor that actually didn't respect them, didn't listen to them, didn't go along with their needs and expectations. They felt he was the bad doctor and they had the feeling that they need to change that doctor. Then they changed to a different doctor that actually listened to them, that went with their expectations and needs, and actually was smart enough to make their oncology plan very flexible, and was thinking out of the box. We found that most of those patients had that practitioner physician that actually went at those traits, if we can say that. Can you think that, is it true that when you're talking about out of the box, that could include, for example, an openness to herbal medicine, or to practices like that? Is it a? Interesting thing is that, we actually asked them, all of those patients, we asked them if they thought that actually complementary therapy had any significance in their survival? In their-. Exceptional survival. Exceptional survival, exactly. All of them used complementary therapies, but all of them said that they didn't think that complementary therapies were the significant part that actually led to their exceptional survival. They felt the two points: having an exceptional physician or exceptional practitioner and being active in their own care, was the two main things that actually increased their survival. So, they talked about the physician as a kind of remedy? As a kind of remedy. Not as a kind of remedy, but as unique interactions that they had with a physician, or a caregiver, or a practitioner that actually made their all trajectory a complete different journey. So, listening to you, I must ask. One of the controversial aspects in integrative care, we feel much safer about quality of life treatment and so on, but we don't touch, usually, the issue of survival. But, do you think there's any impact of an integrative practices about patient survival? I'm not talking about specific effects of acupuncture point this or that, or specific herb, but the more non-specific effects of being treated in an integrative setting, can it impact survival? I have a feeling that probably there is. I think I published a paper on that. That the issue of lifestyle changes actually affect patients survival in cancer. The issue, the mind-body connection have an effect. We know from conventional studies, when you actually provide good supportive care, they actually live much longer. So, I strongly believe that we need this integrative approach to be utilized, and I think it does have effect on survival. Well, I would like to thank you for the little time and for coming here and sharing your ideas. Thank you very much, Moshe. Thank you.