Okay. My name is Vinjar Fonnebo. I'm a Professor of Preventive Medicine at the Arctic University of Norway which is in Tromso, Norway, the northernmost university in the whole wide world. NAFKAM is also a research center that I'm in charge of, which does research into complementary and alternative medicine and also gives information to the public and to health professionals in the area. The NAFKAM was established in 2,000 and so I've built it up from scratch. We are now about 25 people working in Research and Information and giving the Norwegian people and health professionals the basis on which they can make choices with regard to CAM. I'm also a Professor of Preventive Medicine as I said in general at the university. So, I would like to ask you. Regarding the issue of safety in supportive cancer care. How would you advise healthcare practitioners and maybe patients, the two sides of the doctor-patient dialogue to communicate about safety issues? What is safety in the context of supportive cancer care? Well, first and foremost at NAFKAM, we do have patient safety as one of our main topic areas both with regard to Research and Information, and we have a special focus actually on cancer. We claim that first and foremost, a healthcare professional needs to be open to discuss use of CAM, use of herbal products, use of dietary supplements, with a cancer patient. There are way too many health professionals that do not engage into that kind of discussion, and we think that that is the number one in patient safety that they feel that they can discuss this with their health care professional. Health care professionals are the number one choice for patients, whom they express that they would like to discuss this with. So, we have to just establish that. So, that's our number one. Number two, is that cancer patients around the world use different kind of CAM practices. In almost every country, this is studied the thing they use most are herbal products dietary supplements. So, patients and healthcare professionals, they need to have access to information about these products. One thing is whether the product has any effect on their tumor, or their well-being as a cancer patient. The other is of course side-effects or harm that can be experienced from using these products. So, in that area, we have built on a European project that was developed many years back. This project has developed a website called CAM cancer, that gives information to healthcare professionals and also to patients about over 70 different CAM practices. A large portion of those are dietary supplements and herbal products. Our ambition is to give information that is up-to-date and we have a very thorough editorial process, so nothing on this website is older than 24 months. Everything is based on available research. So, patients and their providers can go to the website and get informed about what is the research status with regard to these products or treatments. I would like to ask you, there is lot of literature about the question of disclosing complementary medicine use to oncologist or to other health care practitioners. Who should initiate this conversation? I mean, from ethical, legal, clinical, from safety perspective, who should initiate it? Is it the responsibility of the clinician, of the patient? In my opinion, it is clearly the responsibility of the oncologist or the general practitioner. Whoever healthcare professional these patients access, it's their responsibility to ask the patient what they're doing. They know already from the literature, that half of their patients are accessing. It should be just natural for them ask about what they were doing outside a conventional healthcare, as they asked them if they smoke or drink too much or how their life is with their family, because it can influence both the clinical care and in addition the patient really want the oncologist to discuss this with them. But of course if they do that, they have to be very careful that they're not judgmental. They have to express that they respect the choices the patient takes, and then they can give advice. If they are able to establish that kind of relationship, the patients at least, our study show that the patients are not expecting the oncologist or their general practitioner to say, "Wonderful. This is great that you're using these things." They want advice. So, the patient will be very happy if the oncologist says, "Okay. I can hear what you're using. Now, maybe you should not take this for this reason." They have to be informed and then the respect from the patient will be established, and they can then make their choices from the recommendation. So, I think responsibility is clearly on the professional. So, would you expect the oncologist or GPs to include a question about herbal use or complementary medicine use, routinely in their history taking or anamnesis that should be routinely incorporated? That is my opinion. In every meeting I have with medical schools, with hospitals, with clinicians, with professional societies, I repeat exactly the message you're saying. This should be as routinely collected as anything else you have as your points in your history taking, because it's important for the patient. Not only for cancer patients, all patients I would say. This is really important. You're talking about non-judgmental approach. So, even if a clinician objects the use of this herb, or this supplement, or another modality, I understand that it need to be documented. I mean, it need to be not hidden under the table, but something that is part of the medical file. That's exactly correct. In our modern time now where we are so much emphasizing patient centered care and patients choices in care, it's not for the clinician to object to whatever the patient chooses to do. It's for the professional to give advice and to help the patient in taking wise choices with regard to their care. That's what the patient is expecting. How would you expect a clinician to give advice, to consult patients, about use for example, of herbal supplements. In terms of safety, I mean, there is no doubt that there is a need for effectiveness study and research based study. From the perspective of safety, how would you balance effectiveness and safety in cases where there is some evidence for effectiveness, and some questions regarding safety or risk? Well, I think that is with regard to cancer patient. That is very much a question of at what stage they are in in their cancer. Like we have in my country as in other countries, several tragic cases where patients are using some CAM practices, that are very clearly damaging to their health. Especially, if they then deny conventional care. Like early stage breast cancer patients, we have a number of those that have died totally, unnecessarily because of that. So, in that phase of the disease of course, the safety concerns are very, very prominent because the effectiveness is so marginal. Maybe if we're talking about a terminal patient that wants to try something, then that's a very different story because the safety concern is very different and the potential possible palliation of something might be valuable for this patient. Then there's another aspect and that is of course the financial aspect, because as I always say to both patients and health professionals, you have to always think about whether what you are asked to pay for this treatment is in any reasonable relationship, to what they claim would be the effect of the treatment. In many cases, especially like in the terminal phases, there is clearly an exploitation on a few CAM practitioners. The general CAM practitioner, I don't experience that, but there are a few practitioners often non-organized, that really exploit terminally ill patients and that's a tragedy. What's the situation in Norway in terms of herbal use? Is there any data concerning the herbal use or complementary medicine use with patients in cancer? Yeah. Is it around 50%? Around 50% use CAM and the most common use is in the supplements, the herbal products and that. That's the most common. They look for products, they buy them and they take them. Okay. Can you just specify if there are any centers in Norway or in Scandinavia that you can say they integrate complementary medicine as part of the oncological treatment? As far as I know there is no oncology department in the whole Scandinavia that integrates CAM practices, but their all oncology departments are very positive to a number of lifestyle, improving initiatives. But if you talk about what we know as specifically CAM practices as far as I know, there are none with one exception. Which is? That is at the University Hospital in Trondheim, Norway. They use acupuncture as treatment for nausea; chemotherapy induced nausea. They use acupuncture. That's the only one as far as I know.
