I'm Rejin Kebudi and I'm the professor of pediatrics and pediatric hematology oncology from Istanbul University. Istanbul University Oncology Institute. I'm the faculty of the Turkish Pediatric Oncology Group, and I'm also the chair of the Supportive Care Working Group in the International Society of Pediatric Oncology. Wow, that's great. I'm happy that you're willing to go into this interview. Please tell me from your experience as a pediatric oncologist, what's the prevalence of use of herbal medicine in Turkey, in patients that undergo oncologic care. Yeah. Well, today in the whole world and in Turkey, the survival of pediatric cancer has increased dramatically in parallel to the advances of combination chemotherapy, surgery, and radiotherapy. So, conventional treatment is very important pediatric oncology. Most of the patients and parents wanted to get that conventional treatment and they do get it. In Turkey, all this cancer treatment and cancer care is free of charge. It is all reimbursed by the government, but many of the parents and families will use some kind of herbal medicine or supplement in their daily practice. This is not the alternative treatment. We never, never recommend alternative treatment as herbal treatment or other kind of treatment to conventional treatment in pediatric cancer, because we have such good survival rates. But integrative medicine complementary medicine can be done. In that aspect Turkey is like a botanical garden, because there are so many plants, and there, many of the patients both adult patients and children or families of children use some kind of herbs. The important thing is that we have to know what they are using, so when we tell the parents is that if you're using something because many will use it and will not say it. So, what we say, tell the parents is that if they are using any kind of herbal medicine or herbs, it is within the food probably. Please tell us about it, so that we can note it, so that we see whether it has any side effects or increased toxicity of chemotherapy or decrease the effect of chemotherapy. So, we have to know what they are using. Some of the parents come saying that whether the cancer may be caused because they didn't give them the right foods. We say no. Please, we are sure that you have fed him good and it is not because he didn't eat these kind of food and there is no magical food or herbs that will cure the cancer. However, sometimes for some symptom control, some of the medicine of some of these plants may help or for just for the immunity it may help. We advise them to always eat healthy food rich in vegetables and fruits, which have a lot of vitamins and minerals in them. Many of the parents will use some of this traditional herbs that they have heard from their grandparents and their mothers and their fathers. When we did a survey in Turkey also, most of the families we'll use, for example, stinging nettle. Either they will use it as a tea or the seeds with honey. They use, let's say, use garlic, they use rosehip, some use oleander, that's all, they will use red peppers, for example, tomatoes and they have lycopene you know. These kind of things, as long as we know what you are using, is okay and we tell them to tell us about it. Like they would use the black cumin a lot. The cumin is globally now being used a lot, but normally, it is in the Indian food curry. But, although it is not traditionally used, but some will use it because there's some literature about it. But in children, we always are very keen and we want to point out always to the parents that the conventional treatment, having the combination chemotherapy, surgery, and radiotherapy when we need it. For example, in leukemia/lymphoma only chemotherapy. There's a high survival rate, so we want the chemotherapy to be used and if they are using any kind of additional integrative medicine, like plants or other medicine, we want to know about that. Because we don't want the effect of the real evidence-based treatment to increase or decrease, as increasing toxicity or decreasing efficacy. So, this is an important point. Also other kinds of integrative medicine like acupuncture, yoga, and so on, it's not very common. But there are people using it. Spiritual therapy, some parents want to use that kind of therapy. These kind of therapies are also in the literature and they have helped the children. In children, play therapy is very important, and when they will distract their mind, they will decrease the pain. For example, art therapy, we don't have many art therapists. In fact, we had one volunteer art therapists that used to work with us. At that time, it was really incredible how these children would benefit from it. Decreased the pain, decreased their anxiety, art or painting is such a nice way to decrease the anxiety. In fact, the art therapist was a psychologist and she would know about the feelings of those patients at diagnosis within the therapy and sometimes in terminal treatment, terminally ill patients. So, these kind of interventions do help patients, and in fact, in the literature, we can read about the evidence about this. So, the conventional treatment is very important pediatric cancer, but the integrative medicine that we know does not harm the patient. May be used especially not in the days of chemotherapy, because for example, there has been some publications like grapefruits and a pomegranate, which are quite healthy fruits can interact with some chemotherapy. So, if we don't know the side effects and that kind of thing, we would say don't use it within the days that you're getting chemotherapy. Would you consider training of a nurse or physician in your department in complementary medicine? So, there would be a professional in your team that could consult on these areas? That's very important because we have to do everything evidence-based and people have to be trained about this. Of course, the number of doctors, the number of nurses, the number of health staff, these are limited. So, we need to have more nurses to do this, so that we can have one nurse, for example, have a nurse that does education, like the eating healthy food, what they should eat, what they shouldn't eat, how to protect them from infections, the cleanliness, and all that in the environment, what's important for that. So, these kind of nurses can be also trained in integrative medicine, because, for example, adults, there is much more evidence at the moment for integrative medicine. For pediatrics, it's more limited, although there is still a lot of evidence by this time. For example, we know some of these, like the milk thistle, has been reported to decrease the liver enzymes in ones that have elevated liver enzymes due to chemotherapeutics using leukemia. So, it is important that we train a nurse or a doctor is trained with the evidence based in the literature, and so they can tell about this to the parents. Because the parents have a lot of questions about this, and we never use things that we don't ever recommend some of the plants that we don't know the effect or side effect of too much. Because these are children and a dose may really harm the child. So, everything should be evidence-based. It would be nice to do that. Now, if there would be an evidence-based training in complementary supportive cancer care or integrative supportive cancer care, what would be the most important symptoms or concerns you feel there's a need for an extra treatment beyond the superb conventional treatment that you already can offer patients? Well, in the support of care nowadays, there's a lot of improvement done. In fact, the increase in the survival of childhood cancer has been parallel to the increase both in conventional chemotherapy and supportive care. For example, infections, antibiotics, antifungals, antivirals. To really save the life of the child, we have to do it immediately. Like in pedia, febrile neutropenia, we have a lot of it with us, and we have the guidelines. For nausea and vomiting also, we have such powerful anti-emetics. I can remember the 1980's when people would use, would really vomits so much after a Cisplatin chemotherapy. Nowadays, we have much, much powerful anti-emetics, but still, we can use that. We would always think that we will use the anti-emetics, the infectious disease control, and drugs for infections, and all that. But, for example, for constipation, for diarrhea, for some neuropathies, we may use both the drugs that are evidence-based, and some integrative medicine may help. That acupuncture in adults have proven to be quite powerful in neuropathy or in pain treatment. Those kind of adjunct therapies may help these children as well. So, you're welcoming such a training but inside the science boundaries as part of conventional care. Yes. Always, it should be done evidence-based within the science. Because as I say, children, sometimes babies, such like 10-kilo baby or 20-kilo small child, if we use some herbs or material that is not evidence-based, we may harm the child, so everything should be evidence-based. Of course, we have to take into account the traditional medicine that has been used and there is evidence of for many years. Maybe these can be used in a small trial to compare it whether it will be proven effective. So, these kinds of trials are also, this kind of science is also welcome in our field. I would like to ask you about the role of the caregiver in the child's treatment. One of the things, that I as a family physician, all the time wanders. You give your precious time, and sympathy, and the energy to the child, and sometimes the family, the caregivers are the ones that I feel need also treatment for their anxiety. Sometimes, for spiritual concerns that they have, what will be for recurrence? All those questions that we deal with. Especially when we are parents, it's much, much challenging. I wonder if you think that an integrative approach could be targeted not only to the child's quality of life but to the caregivers concerns as well. Well, it's very important in pediatric oncology from the time of diagnosis. It is very important that we care for the caregivers, the parents. For example, when you say that the child has a cancer, it's a shock to them. So, when we have a child with a fever, only for acute tonsillitis, where really, as mother or fathers, were so sorry for the child because they have fever, and then they have cancer. Really, it's a very shocking experience. Well, at the time of diagnosis, during treatment, and we don't want that. Nowadays, there's over 70 percent survival, but that means 30 percent may eventually cure, or progress, and die. So, we may have terminally ill children as well. In that case, it is very important to support the family, the family members, the parents, sometimes grandparents. A psychologists should always be within the team. A social worker should always be within the team. Sometimes, there are not enough psychologists or social workers in many of our government or university hospitals. They really need a lot of care, so it is very important to care for the caregivers of the children with cancer also. Okay. Do you have any concluding remarks, something that you would like to add? Yes, I should add that. In pediatric cancer nowadays, the survival rate is very high. It's always 70 percent. Like in the United States, 83 percent. In West Europe is 79 percent. In East Europe is about 69 percent. In Turkey, although there are a lot of advanced diseases, is 65 percent in the whole country. In some tertiary centers, like in Istanbul University and other universities is over 74 percent. So, the cure rate is quite high, and this cure rate has been achieved using the evidence-based combination chemotherapy, plus or minus the surgery and radiotherapy in certain solid tumors. Also supportive care, because when we use the combination chemotherapies, and we use quite high doses in comparison to adults, we need a lot of supportive care. Supportive care means combating the infections when we have neutropenias, and nausea, and vomiting, and diarrhea, and constipation, and all that. So, we need the conventional evidence-based treatment. But among that, sometimes families want to use some plants, some traditional treatment. We have to be open to cultural differences, and we have to respect the cultural differences, the religious differences. We have to respect the diversity in the patient's whatever their ethnic origin is, or their religion is, or their traditional, cultural background is. We have to respect what they want, and if it can be given within the context of the evidence-based medicine, if it will not harm the child, it may benefit psychologically and sometimes therapeutically, that we have to respect their desires. Thank you very much. Thank you for giving me this opportunity.