I have the pleasure to introduce Professor Gil Bar-Sela, who is a oncologist and the deputy head of the division of oncology in Rambam Medical Center, which is part of the Technion Faculty of Medicine in Israel. Thank you for coming for this interview. Nice having you. I would like to ask you Gil about the issue of palliative care. What is palliative care according to your perception and how does it different from the classical oncology perspective? Well, the palliative care is actually all the time changing. The definitions are changing all the time. Historically, it was a treatment of end of life care and it's still the main issues that's it's dealing with. But the subjects that are actually quality of life are now widespread to other area and this modern concept is that every patients who was diagnosed with cancer need supportive care. What we call that it's actually widens as the borders of the palliative care and although it will not be into so extent as end of life care, still he will have problems, symptomatic problems. During all the treatments period probably later and even the care of the survivors that it's completely different from palliative care. It's still dealing with the same problems like palliative care, but in a different level. So, if we're looking on the wide definition of supportive and palliative care, we are mainly speaking about palliative care near the end of life, it's more convenience to make those differences, because it's allowed us to be more free in the attitude of treatment, to look on things on different ways and if we are dealing with supportive care. But the main issue that we are taking care of the patients, of his symptoms, and not dealing with the disease, it's all the line, it's working the same all the line, but I must say that's of course a disease connected because most of the symptoms are related somehow to the disease and if you improve the situation of the disease probably the symptoms will be better as well. So, you cannot separate it, but in the way that you are thinking, it's better to make this definition that we are related to the patients, focus on the patients and not on the disease treatment. I know that in addition to your speciality as an oncologist, you have extensive training in anthroposophic medicine and in other complementary medicine modalities. I would like to ask you, you have created a unique integrative setting inside your division of oncology. Can you elaborate about that how it works, I mean how patients are referred, who is treating, who in this? Well, essentially what I trying to do, and still not fully succeed, but really try is to focus on two things. One is the service for the patient and that's mainly focus on the different therapies as are more with soul-body, body-mind, it can be also a kind of massage therapy or something like this. But it's not with medications or it's not with supplements and so on. All those things of supplements/medications national product and so on, to put it on study projects and try to know more about them, to gain more knowledge that it's really missing if you're looking on most of the products. If we're looking into the data and try to bring them into clinical trials sometimes, smaller sometimes, bigger, but if it will not be made on cancer center, it will not be made at all. So, it's seen as a big center cancer center in Israel, it's of course if you're interested in it, it's our duty to try to bring things into research and give information that it's more specific, disease related, symptoms related, and so on. On the area of the service, we need to bring all the complementary medicine in order to improve the quality of life. Of course, it's possible to do studies as well as in this area, but it's more or less studies of service to try to understand how such a service can influence the quality of life of patients who are on active treatment. So, I'm trying to work in to those two aspects. Sometimes it's connected to a unique study or a situation, but sometimes it's separate and we are doing studies and we are giving service to the patients. I'm not giving supplements as a service in Rambam, okay. I think we don't have enough knowledge in most of the places, it can be brought into the patients, I know that you are dealing with it here, but I think it should be on a cancer center, it should be more as a research attitude not as a service. So, what happens if a patient, for example, with breast cancer, who is undergoing chemotherapy, comes into your consultation and tell you that she use a herbal supplement, it may be a traditional herb or it may be a more sophisticated herb like viscum album with ampules and subcutaneous injection. How would you communicate with that patient regarding the issues of effectiveness, of safety, of risks of herb drug interaction? What would be your attitude in that scenario? Well, first of all I think it's a different situation, because we have clinic for supportive care, we've several physician, not all of them knowledge is equal about supplements, but it's different when the patient is coming with a list, or with some recommendations that she got from outside and ask, "Can I take it or not? " Always the two are the ones who are prescribed supplements, I think it's quite different. If we are looking together into the Internet, if I'm not familiar with what she brought with her, in most of the things we find that there is no real knowledge about interaction, about safety, about efficacy, about anything. So, usually we have this level of Internet that's things are jumping very fast from something in the lab to something that's it's clinically use and with promotion of the pharmacy who are promoted. [inaudible] those supplements but without any clinical data. So you see, you need to be careful when you are recommended things for patients. But it's more easy to tell them what's the knowledge if you are taking it or not and can be an interaction. We have more knowledge about chemotherapy and interactions, less knowledge about biological treatments, especially all the biologicals treatments are passing through the liver so everything that pass also through the liver can create any interactions that we don't know what it is and you should be more careful with it. We have all the area of the immunotherapies, there are a lot of supplements that so-called are influence the immune system, yes or no, it depends because we don't know. But if it's influence the immune system, we don't know positive, negative, how it interact with new drugs. So, I think you should be careful and not automatically say there is no interaction. You can take it, if it will not help, it will not harm. I'm not sure that we are in this situation. I'm sure that all the naturalist therapists or what they call themselves outside are not familiar with the knowledge, they don't have any knowledge in the new drugs in oncology that are still related to the chemotherapy and chemotherapy-related side effects. But it's only part of the oncology 50 percent, not more. So basically when you identified during the dialogue with the patient that there is a dilemma, like a gap between patient's health belief model and her need for using herbs and your own research-based attitude, what you do in that moment of dilemma is to take the communication into the realm of pubmed, medland, looking for the evidence. How do you deal with that from a communication point of view, doctor-patient communication? Yeah, I think one of the first point of view is trying to see what's the motivation of the patients of taking these kind of supplements, okay? Sometimes, or most of the times, I think the motivation is unknown or unclear. It's not the situation that the patients have a problem, nausea for example, and now she looking for other drugs for nausea. Then it's more easy to understand and it more easy to help her. Usually, it's something very general. I want to improve my immune system. All the people around me say that it's very important. Okay, so then you start to ask her, "Why you think that your immune system is not working well? Why? You have any kind of problem? You have infections? You had many infections in the past that you are more prone to infections? Somehow, why?" In most of the cases, there will not be a real reason, it would be something general. That the surroundings said it's important or she or he personally think it's important but not really something that are really, in a conscientious way, think why should this product should help me. Then it's very easy to find out if there is no real knowledge, that you can help it, maybe you may avoid it just for a couple of months to see how the new treatment is working. That will not be in the situation that something, new drugs are developed and it's given to you and it will not work. We don't know, maybe there was some interactions that we will not really understand and to be a reason that it's not working. So wait a little bit, see what's happen, see if you really need it. Maybe there would be no side effects to add it now. Maybe everything will go right. See what side effects are starting then we can see what you really need. I think there is a lot of movement into complimentary medicine that it's more from the fears of the patients or from their concern before treatment and less of treating real problems that actually coming out of the treatment. I think the attitude should be like palliative and supportive care, it should be part of the palliative and supportive care. It's part of the tools that we have. If there is a problem that it's starting to rise or it's getting on for a long time, then we should see what the treatment can be. It can be a drug from the regular drugs, but maybe it have side-effects. Maybe we can use something from the complimentary or some kind of therapy and it will be with less side effects and less problems, why not to try it if it's still in the beginning. So the attitude is a clinical attitude. The same way that you use regular medications in palliative supportive care, you should use complimentary medicine and not separate your mind because this is complementary and this is allopathic. So in addition to being a medical oncologist, you are a specialist in palliative medicine as well? Yeah. I would like to ask you what's the added value of integrative medicine, or anthroposophic medicine specifically, in palliative cure. Are there other any niches or places where you feel that palliative care does not have enough therapeutic tools and that integrative anthroposophic care can add something? Okay, I must say that first of all, it's not only palliative and supportive care. For example, it's data that is not probably published but it's going to be published in the next year. You are probably familiar and you may also research in wheat grass juice. We made a three year study of patients who are taking adjuvant chemotherapy in colon cancer. We include half of them get wheatgrass juice with the chemotherapy and half of them not. We don't have the final results of all the 100 but for the first 50 who finished all the period, we make also a laboratory studies on microparticles. Microparticles are a small vesicles that are getting out of cells of endothelial cell and also from tumor cells, and they were different for the patients who took wheat grass or the one who not. We see that it's influenced the thrombogenicity that caused by the chemotherapy and the endothelial damage of the blood vessels, and so on. Of course, it's not something clinical, it's more laboratory, but you can see that nutritional support have influences on the levels of the body of the cells, and so on, that maybe it's important for your continuous life and not for this moment, like supportive care, symptom care, of the problems that you have in this moment. So it's more wide but many of the studies, and especially what I made with anthroposophic medicine, were specific to supportive care. We make mainly studies with mistletoe, I can give a little bit more widen view on it. The viscum album, what's we called mistletoe, but we also made one study with art therapy in influence of fatigue, depression, anxiety. That was showed like other, I don't think it's only the anthroposophic attitude of art therapy because other studies show it as well that it had positive results on those subjects. There is another interesting study that we just published I think two years ago or one year ago. It was on the services by itself, that part of them it's anthroposophic-related therapies and part of them not, what all use. But we also tested the long-term after we've finished the treatments because most of the studies showed that the main influence is during the treatment period of the therapy. After you stop the therapy, even it's art, shiatsu, or in music therapy, the influence will disappeared. So we tested during six weeks period and after another six weeks, and we showed that it stayed for a longer time. So there are probably some longer influences of therapies and it's not only in the short term, and I think it's very important when you have such a service to know that the influence. Taking for a long time, and you can give the service for a period of time because you cannot allow it to everybody anytime, all the time, and you also improved on the long term or on the short long term run and not just if you are doing the service or not. So, l think those subjects are important as well. But most of my studies were on the Viscum album, once a mistletoe. There were a few studies. One studies that actually was in a palliative indication, it was with patients with recurrent ascites. We inject Viscum album into the peritoneal cavity after taking out the fluid. So, it was in the same needle, was done in same needle. We showed that the intervals between the paracentesis were prolonged if we compare it to the time it was for every patients before it's the time that he need to do paracentesis. So this is a completely palliative indication, but we also try to see if we have influence on the cancer itself. Ten years ago, something like this, we made a study with colon cancer patients after they finish other treatment possibilities and to see if we can reach to some tumor response. We didn't reach to a response, but 25 percent of the patients had prolonged stable disease. So, it's also may allow something that really interact with the cancer itself and not only on palliative indication. The last study that we made was with lung cancer patients in advanced disease. During chemotherapy, first-line chemotherapy period, half of them got a Viscum album during this period. There was, actually, the question is for quality of life we're not statistically different but we're less hospitalization in the patients who took Viscum album. They kept the dose of the chemotherapy. They didn't need to have dose reduction and they had less side effects, non-hematological severe side effects. So, it's really improved the treatment. Now, I'm in a situation that's actually I'm trying, I'm planning. It's not started yet to do a phase one study with intravenous mistletoe, Viscum album, once a week, try to build it as a regular phase one study to reach to higher level and to see if there is any anti-tumor response or stabilization of the disease. Of course, it's not the aim of the phase one study but the aim of the study is to reach to the higher level possible with IV injection once a week. So, I think this kind of research, plant research is very important to do in the regular oncology. It's hard to get support for such a research because it will not be founded. Those medication will not be founded in the ways that you can do a good clinical trial but a large cancer center can allow them to do such studies with less founding, I think, because they have the founding from other studies and they can move it to such kinds of studies that it's very important to the daily life of many patients. There was a study that you did with wheat grass juice that you just talked about but that was your initial study. Yes, the initial study was 10 years ago, actually, with chemotherapy. Breast cancer patients during adjuvant chemotherapy [inaudible]. It's in a base and that tested the influence on actually on blood count. We didn't see a difference in the white blood count but we see differences with what we call neutropenic fevers. There will less neutropenic fever in the groups that use this wheat grass. The frozen wheat grass. It was always frozen because it should be. I think, it should be very easy to take and to handle. The new studies also is done with frozen. We also showed that the hemoglobin, although it goes down in both group, but it was statistically different. The change was less in the groups that use the wheat grass. It was a small study but still I think the results are very important and very important to report them because every patient can use it and we didn't see differences in other side effects except for the test and some nausea that can come with a wheat grass or in the long-term follow-up of recurrence of disease, second malignancies and so on. You should also look for them because maybe you take some of the influences of the chemotherapy by giving antioxidants or sons that can be a part of the wheat grass. What strikes me in your studies is that you're very clinically oriented of course and that you're not just focusing on quality of life issues but all the time you are looking at the oncologist's side as well. What's the meaning of this quality of life improvement from the prospective of the oncologist in terms of neurotoxicity that hampers the treatment that you designed? Quality of life is coming part of any new studies. Actually, you can't get FDA approve or EMA approve if you don't have part of quality of life in your study with a new medication. On the other hand, if you are doing just studies that focusing on quality of life, then it's very hard to show the difference between just doing the intervention or the influence of the intervention on quality of life. If I'm not clear, if you are doing any intervention. It was showed with studies that made with the influence of Ritalin. The couple of studies, very large studies published in the Journal of Clinical Oncology that tested the influence of Ritalin and Memo-rite for example on on fatigue to see if it's influence to fatigue. The study's plan was based on daily phone call of a nurse that asking you about your quality of life and all those issues around and both groups improved the same. There was a 50 percent improve just, of course, from the calling of the nurse for a daily phone call. So, just making intervention, it's improving your quality of life and if you're doing a study on quality of life and just part of the patient's getting the intervention, you will have positive results from the beginning, okay? So, it's hard to plan a quality of life study in complementary medicine that will have two arms that we have a sham intervention like you can do with acupuncture for example, and that's why those study are in higher level, I think. So, you can show improvement just by doing the study, okay? And asking the question, so you need to be very careful on interpretation. So, I tried to find endpoints that are more clear for the study. So, let me ask you again about palliative care indications in terms of integrative interventions, and to start with fatigue, with cancer-related fatigue or chemotherapy related fatigue, where do you find an added value of integrative treatments, and specifically herbs or mistletoe, but our intention here is with herbs specifically? Where do you find the added value of herbal or anthroposophic interventions in alleviation of cancer-related fatigue? As I said, every intervation, every therapies that we start has a good chance to improve fatigue just by doing it, and it really depend for some patients, it will be psychological talk. For the other, it can be music therapy. It's a basic thing, that if you add something, it can be very helpful. That's a nonspecific effect. That's a nonspecific effect. That includes these therapies, anthroposophic therapies that are more art-related, and try to work with the soul, the power of the soul trying to influence the souls that will influence the body through art process. That's very specific to the anthroposophy attitude with specific exercise that you can do in each therapy that has the power to influence what we call the life forces, and can be translated into a fatigue if you want to be more medically-oriented. Also, the mistletoe, the viscum album from the anthroposophic point of view is related to what we call the life processes. So, it's related to fatigue. Actually, there are many studies that are done with the endpoint, secondary or primary endpoint of a fatigue, that show a good improvement in this subject and other side effects as well, but fatigue is something very general that has a lot of influences from different directions, so it can be related to body, soul. But, of course, if you have anaemia, so you will have fatigue anyway. So, it's very hard to discrepance between the different subjects that influence fatigue. But in general, many studies, not done by me but by others, viscum album comparing to Chinese medications. So, two-arm randomized study, not double-blind but randomized, shows the good influence of viscum album on fatigue, so it can be helpful. Actually, many patients are reporting, because on treatments, they had fatigue, started the mistletoe. So, patient-centered report, part of them are reporting very good influence of mistletoe in general. I would like to ask you regarding pain management, if there's any value of anthroposophic medicine to pain management either in supportive or palliative care? Well, pain with cancer patients, it's a big issue. Nearly, every patient near the end-of-life who suffered from some level of pain and third of them, it will be very hard pain to treat even with the regular drugs. So, I don't think that anthroposophic medicine can be, instead of the regular anti-pain treatment, but it can be with added value in specific problems. Sometimes in inborn pains are specific compresses that you can use or ointment. What kind of ointments and compresses? We use Symphytum from the plants. Symphytum or Symphytum with Arnica for bone pains. Sometimes, a very hot lean compress on a specific site of that you've got the pain. It can be helpful. Sometimes, it's related pain, but it's not a cancer pain. You can have aphthous in your mouth, so it will cause a lot of pain. You can have neuropathic pain, and then you have treatments, but it was not tested really on clinical studies. It's more clinical use that you can try and see what's helped, and so on. I will not make it any regular recommendations for use. It's just something that you can see with your patient, asking to try for one week, two weeks to see if it have any good influence on the pain. But I must say that we have a lot of medications, and if it's related to cancer, you have all the treatments in oncology, mainly radiation. For example, for bone pain, most of the of the pain, cancer-related pain is actually related to bone, and somehow the severe pains. So, you need to look to other areas that it's influence is bigger, because the pain is in higher levels than other pains that you have in a regular basis, that probably are managed better with anthroposophic medicine. Viscum album has an advantage in terms of pain if you add it to morphins and other drugs? I don't know if it's tested. I know there is a big studies that started in Germany, should start with Helixso in the end months of life, because they think it's really can improve all symptoms they have. From a smaller studies, they have very good results. Now, I think with the support of the Germany government, they are doing a larger study, but it's not started yet. Probably be related also to pain, but, because it will take all the period of the last months of life to see what viscum can do there. But until now, I'm not familiar with any specific knowledge related to pain and treatment with viscum. What about anxiety, depression, insomnia, and other sleep-related problems? There are anthroposophic medications that are more specific. If you go into insomnia, there are many reasons why a person has insomnia, and you need to ask more to relate it to a specific treatment. Viscum as general, because it influenced what we called life forces or quality of life in general, can also influence those issues in general, as it was showed in few studies that also asked for those parameters in the questionnaires. I must say that now in Israel, for all those symptom-related cancer, we use the cannabis, what we called medical cannabis, that it's legally and allowed for advanced cancer patients for symptoms relief, and it helps mainly in insomnia. Very good for insomnia. In depression, it was not helped. There were studies that were not cancer-related, but depression in general, that was treated with cannabis. It was not helped. But anxiety, it was helpful, and also in pain. Mainly, if you give it together with opioids. So, large part or big part of the patients with advanced cancer are using the cannabis in the last year of their life or during treatments as well. Part of them with very good influences, and there are many studies, few of them published also. We made in the past, but now there are more prospective studies with specific primary and secondary endpoints that are trying to be more defined with the influence of cannabis. They think it's very good to try, and it's also part. Maybe it's not so complimentary because it's a drug, and you need the governmental license for getting cannabis, but I think it's a big context of what we're dealing with. It's a herbal medicine. It's a herbal medicine, yeah. Okay. So, with that, I would like to thank you for coming here and sharing your knowledge and expertise with us. Thank you. Thank you as well.