CANCER treament MANAGEMENT

THE BIG SIX

After I brought patients to my office and described the options for treatment, and then the details of that treatment by using my dry erase board and numerous visual aids and models, I would ultimately get to the question of “what's essential to do during

treatment?".  As always to help people remember things without a bunch of work, I use the acronym BIG SIX to deliver the answer and would write it on the board with explanations so they can use their cell phone and photograph it upon leaving. Now I pass it to you on this website so you can bookmark this page for easy access.

How Many Steps Do I Need?

Many of the common cancers treated daily in the United States are highly curable with manageable or low toxicities. These favorable ones include the early favorable breast cancers, prostate cancers, and first stage one tumors of other sites of the body such as colorectal, uterine, bladder and so on.

 

  • In these favorable cases, I would suggest using step one, two and three as a hedge during therapy but also going forward to prevent new additional cancers in the future.

 

 

I was thrilled to see some presentations recently at the Metabolic Therapeutics Conference in Long Beach California 2/2019 where families found a way to execute the keto-genic diet and use hyperbaric therapies during standard treatments with remarkable outcomes in pediatric brain tumors. Pediatric gliomas universally carry a poor prognosis measured in months, and three presentations of individual results using the above principals were truly remarkable and encouraging.

B is for BREATH


Our most crucial nutritional requirement namely; oxygen. Nostril breathing is critical to a maximal exchange of oxygen. It purifies and warms the air, activates parasympathetic tone to keep the patient in a calm “rest, digest and relaxed” state as opposed to “fight or flight." Somehow most of us get through medical school without really understanding the dynamics of breathing. Nostril breathing can exchange 6 to 10 liters of air per minute on average while providing adequate oxygenation. Mouth breathing alternatively, exchanges more air in the range of 10 to 16 Liters which does not increase oxygenation at rest but blows off more CO2 making the levels go down in the microcirculation and greater difficulty in releasing the oxygen to the tissue (hemoglobin needs some CO2 related acidity to best release the bonded 02). Newer research even supports that as soon as we go into mouth breathing, we flip over to glycolysis or sugar burning metabolic pathways creating inefficiencies and greater oxygen demands (oxidative phosphorylation via fat burning requires one-third less oxygen to produce the same amount of ATP). I also mentioned that flipping over to mouth breathing/fight or flight frequently through the day triggers a cortisol response which sabotages our bodies natural ability to generate an immune response to fight cancer. Our bodies strive for survival and when in “fight or flight," our systems ditch longer term needs such as immune function and healing in preference to immediate survival. I may even practice some breathing techniques with the patient such as the typical relaxation breath of 3-5 seconds nostril inhale followed by 5 to 8 seconds nostril, and mouth exhales with a relaxation of the upper body on exhale. I suggest they use nostril breathing at times of anxiety such as during the actual treatment on the machine or in the chair. I sometimes would mention box breathing with a comfortable hold after the inhale and after the exhale typically used for focus end alignment. Generally, this discussion opened up a whole new arena for exploration and once again transformation for the patient and his family. A final word on that; " when in doubt stay in your nose."




I is for INGEST


Ingest food and water. This is the part where we give some simple basics but go into more depth if the patient and family are interested.

  • Morning Detox with Water:
I ask every patient to take ownership of a morning detox or flush where the first thing they do is drink down 16 to 24 ounces of water immediately upon rising. If they're not at risk for hypertension, I suggested they put good sea salt in it, (about one-half a teaspoon), and if they have heartburn or constipation consider placing a tablespoon or two of aloe vera juice in each glass. They need to do this every morning like a robot, whether they're thirsty or not. After this step they can consider tea or coffee hopefully consumed without refined sugar, possibly with clean fat in it, and from a ceramic mug and not a Styrofoam cup. I try to get patients to take ownership of their hydration status recognizing that their bodies are 75% water and that their performance significantly drops with mild dehydration. I also remind them that there is generally little harm by drinking too much unless they have a heart failure problem and that during treatment many medications can mask our typical signals that we need to drink. I suggested repeating this mandatory rehydration two further times through the day possibly mid-morning and mid-afternoon. And generally, at mealtime, water is the preferred drink. I point out that products with sugar in it such as soft drinks, juices, or alcoholic options trigger insulin level elevation, and thus proliferation drivers and may sabotage cancer control goals.
  • Eat Real Food:
The second part of ingestion includes food options, and I simplify it by saying remember to “ eat real food, like what grandma and grandpa ate." Choose options that don't have a shelf life or descriptors that sound like a chemical brew. I briefly describe the metabolic theory of cancer as demonstrated by fructose driven cancer uptake in the pet scan, sugar is the preferred energy metabolite for cancer growth. I assure patients we can support our bodies and destabilize cancer by choosing clean fats and avoid and minimize refined sugars and carbohydrates in our dietary choices. I remind them that grains break down into sugars, so steer your decisions toward healthy meats, fish and copious vegetables dressed with clean fats and oils, nuts and spices. When choosing fruit, I suggest picking the berries which have high polyphenols and a lower amount of sugar. For those that are highly motivated, I recommend they consider a 12 to 14 hour fast before their radiation or chemotherapy treatment. I encourage them to use their water flush of course in the morning, and then maybe black coffee or coffee with clean fats in it but nothing that would trigger an insulin response. This metabolic priming has been shown in animal studies to increase the cytotoxicity of chemotherapy and radiation significantly. Unfortunately, this priming is yet to be proven in a randomized clinical trial in humans because of the challenges of executing nutritional experiments in our hospital environment. There are many beautiful resources to help patients with these new strategies; The Metabolic Approach To Cancer by Dr. Nasha Winters, ND, Fight Cancer With A Ketogenic Diet by Ellen Davis MS, and Keto for Cancer by Miriam Kalamian EdM, MS, CNS, and Thomas Seyfried, Ph.D.




G is for GET MOVING


Although I may come off as a cruel drill sergeant, I remind the patients of the remarkable things that exercise, sunshine and fresh air can do for our spirits and the metabolic signaling in our body. I tell them that a "body in motion, stays in motion." I outline our bodies propensity toward adaption and that once we forgo modest daily activity we will lose our strength quickly and many of the threats that take down our cancer patients emerge as realities. These risks include a fall from muscle weakness and neuropathy, a blood clot from immobility, pneumonia from inactivity and shallow breathing, or just depression and its sequelae from loss of independence due to defect. A daily commitment to some activity even if it is short will make a giant difference in the level of function, quality of life when someone finishes treatment and chance and speed to recover back to their original baseline. Virtually every study that investigated exercise programs during cancer treatment identified reduced complications, improved emotional measures, and suggestions at improving survival through lower recurrences comorbidities. For those people that could not manage to embark on this on their own, we had an excellent program called PRIDE that found a way that everyone could exercise under supervision while emphasizing balance work to prevent falls. We also had a broader program called Exercise Is Medicine. I would always remind patients of the benefit of working out with someone else to aid accountability while serving our social nature. I challenged our patients for those that would listen to ultimately put the twist on cancer by getting stronger through the course of treatment. This surprising and confoundng act would greatly arouse their inner courage to become their future healthy self.




S is for SLEEP


Sleep is KING. The general population is starting to understand the importance of sleep as more people get fitness monitors and the lay press generates stories on the significance of this neglected past time. I try to remind patients that their cancer treatment is their own”Su- per Bowl” and optimal preparation of the body through restorative sleep is critical. I tell them that deep sleep generates growth hormones and sex hormones that foster recovery and is necessary to clear the brain’s toxic buildup.

  • I try to steer them toward non-pharmaceutical sleep aids given the data that most pharmaceutical options reduce deep sleep, become habit-forming, and have significant memory-impairing hangover effects.
  • I encourage patients to stay on a daily rhythm by exposing themselves to sunlight in the morning.
  • Avoid sleep during the day (other than a short nap) to prevent walking the floors at night.
  • Since most patients on treatment become magnesium deficient, I strongly encourage them to take a moderate dose of magnesium in the evening in the range of 400 to 800 mg which may help their sleep and bowel elimination in the morning. See my other suggestions on sleep. I frequently revisit this topic to make sure they're sleeping well through the treatment period.
  • I encourage patients to try to avoid unnecessary adjunctive medications (like casual use of steroids to prevent nausea while preventing sleep the same night) that disrupt sleep. There are many ways to prevent nausea without inducing a state of cortisone driven fight or flight that disrupt sleep, irritates gastric mucosa, weakens immune function and raises blood glucose level and other proliferative markers.
So I remind patients that; "sleep is the most important thing not to screw up during treatment."




I is for INTENTION


A daily exercise of visualizing themselves, with someone they love, looking good and feeling tremendous in their favorite place in the future.

  • I remind them that all victories start in their head with thoughts and intentions. I encourage them not to use angry or perverse words or concepts such as “kill or fight cancer," as these can be contorted with setting intentions.
  • I encourage them always to put the thoughts and images in favorable terms that cannot compete against themselves or anyone else.
  • I suggest they create this original mind video of their fun movie and marinate in it as their first thought in the morning and last thought before going to sleep, and anytime they feel worried or fear coupled with steady nostril breathing.
I confessed to them that anything good that has ever happened to me started with a dream or stretch story and that this tool is used frequently during their treatment. I acknowledge to them that it sounds unscientific, but creating the future vision they want to have is necessary and needs to be coupled with the additional realistic steps incorporated in the BIG SIX.




X is for EXTREME LOVE


Men sometimes retract when this final concept comes up, but women are right in step with me as they know that the most potent force we have in our lives is love. Just like when I ask patients to identify their purpose, generally it is rooted in love. I remind them that difficult and monumental achievements require motivation and power that can only come from love. I put this concept on the table so they can go right to work on a transformation if necessary or maybe just upgrading the emphasis on love in our daily actions. I point out that it is nearly impossible to have fear or anger and love at the same time and which would they instead spend time with. Most cases of remarkable recovery involve some sort of profound personal change (Radical Remission by Kelly Turner). I even go to the point where I suggest that the best predictor of a long-term survivor is one who generates the capacity to get outside of themselves during the problematic cancer treatment and help someone else. Many stories of survivors show a common trait that the circumstances required them to step in and take care of someone else, so they were no longer a victim and became a caregiver (Deep Survival by Lawrence Gonzalez). I encourage the patients to fall in love with their loved ones again, with their acquaintances, and with the strangers, they meet at the checkout line at the grocery store. Once again this sounds flakey and I'm good with that, but there is emerging science that suggests there is intricate communication between cellular mitochondria initiated by our intentions and emotions. After the BIG SIX discussion, I make sure I walk them to the checkout region near the front of the cancer center, reestablish our next visit and with a handshake or a hug wish them well and then remind them that “they will be fine, and they won't go through this alone."





Baby Steps During Treatment

B is for BREATH


Our most crucial nutritional requirement namely; oxygen. Nostril breathing is critical to a maximal exchange of oxygen. It purifies and warms the air, activates parasympathetic tone to keep the patient in a calm “rest, digest and relaxed” state as opposed to “fight or flight." Somehow most of us get through medical school without really understanding the dynamics of breathing. Nostril breathing can exchange 6 to 10 liters of air per minute on average while providing adequate oxygenation. Mouth breathing alternatively, exchanges more air in the range of 10 to 16 Liters which does not increase oxygenation at rest but blows off more CO2 making the levels go down in the microcirculation and greater difficulty in releasing the oxygen to the tissue (hemoglobin needs some CO2 related acidity to best release the bonded 02). Newer research even supports that as soon as we go into mouth breathing, we flip over to glycolysis or sugar burning metabolic pathways creating inefficiencies and greater oxygen demands (oxidative phosphorylation via fat burning requires one-third less oxygen to produce the same amount of ATP). I also mentioned that flipping over to mouth breathing/fight or flight frequently through the day triggers a cortisol response which sabotages our bodies natural ability to generate an immune response to fight cancer. Our bodies strive for survival and when in “fight or flight," our systems ditch longer term needs such as immune function and healing in preference to immediate survival. I may even practice some breathing techniques with the patient such as the typical relaxation breath of 3-5 seconds nostril inhale followed by 5 to 8 seconds nostril, and mouth exhales with a relaxation of the upper body on exhale. I suggest they use nostril breathing at times of anxiety such as during the actual treatment on the machine or in the chair. I sometimes would mention box breathing with a comfortable hold after the inhale and after the exhale typically used for focus end alignment. Generally, this discussion opened up a whole new arena for exploration and once again transformation for the patient and his family. A final word on that; " when in doubt stay in your nose."




I is for INGEST


Ingest food and water. This is the part where we give some simple basics but go into more depth if the patient and family are interested.

  • Morning Detox with Water:
I ask every patient to take ownership of a morning detox or flush where the first thing they do is drink down 16 to 24 ounces of water immediately upon rising. If they're not at risk for hypertension, I suggested they put good sea salt in it, (about one-half a teaspoon), and if they have heartburn or constipation consider placing a tablespoon or two of aloe vera juice in each glass. They need to do this every morning like a robot, whether they're thirsty or not. After this step they can consider tea or coffee hopefully consumed without refined sugar, possibly with clean fat in it, and from a ceramic mug and not a Styrofoam cup. I try to get patients to take ownership of their hydration status recognizing that their bodies are 75% water and that their performance significantly drops with mild dehydration. I also remind them that there is generally little harm by drinking too much unless they have a heart failure problem and that during treatment many medications can mask our typical signals that we need to drink. I suggested repeating this mandatory rehydration two further times through the day possibly mid-morning and mid-afternoon. And generally, at mealtime, water is the preferred drink. I point out that products with sugar in it such as soft drinks, juices, or alcoholic options trigger insulin level elevation, and thus proliferation drivers and may sabotage cancer control goals.
  • Eat Real Food:
The second part of ingestion includes food options, and I simplify it by saying remember to “ eat real food, like what grandma and grandpa ate." Choose options that don't have a shelf life or descriptors that sound like a chemical brew. I briefly describe the metabolic theory of cancer as demonstrated by fructose driven cancer uptake in the pet scan, sugar is the preferred energy metabolite for cancer growth. I assure patients we can support our bodies and destabilize cancer by choosing clean fats and avoid and minimize refined sugars and carbohydrates in our dietary choices. I remind them that grains break down into sugars, so steer your decisions toward healthy meats, fish and copious vegetables dressed with clean fats and oils, nuts and spices. When choosing fruit, I suggest picking the berries which have high polyphenols and a lower amount of sugar. For those that are highly motivated, I recommend they consider a 12 to 14 hour fast before their radiation or chemotherapy treatment. I encourage them to use their water flush of course in the morning, and then maybe black coffee or coffee with clean fats in it but nothing that would trigger an insulin response. This metabolic priming has been shown in animal studies to increase the cytotoxicity of chemotherapy and radiation significantly. Unfortunately, this priming is yet to be proven in a randomized clinical trial in humans because of the challenges of executing nutritional experiments in our hospital environment. There are many beautiful resources to help patients with these new strategies; The Metabolic Approach To Cancer by Dr. Nasha Winters, ND, Fight Cancer With A Ketogenic Diet by Ellen Davis MS, and Keto for Cancer by Miriam Kalamian EdM, MS, CNS, and Thomas Seyfried, Ph.D.




G is for GET MOVING


Although I may come off as a cruel drill sergeant, I remind the patients of the remarkable things that exercise, sunshine and fresh air can do for our spirits and the metabolic signaling in our body. I tell them that a "body in motion, stays in motion." I outline our bodies propensity toward adaption and that once we forgo modest daily activity we will lose our strength quickly and many of the threats that take down our cancer patients emerge as realities. These risks include a fall from muscle weakness and neuropathy, a blood clot from immobility, pneumonia from inactivity and shallow breathing, or just depression and its sequelae from loss of independence due to defect. A daily commitment to some activity even if it is short will make a giant difference in the level of function, quality of life when someone finishes treatment and chance and speed to recover back to their original baseline. Virtually every study that investigated exercise programs during cancer treatment identified reduced complications, improved emotional measures, and suggestions at improving survival through lower recurrences comorbidities. For those people that could not manage to embark on this on their own, we had an excellent program called PRIDE that found a way that everyone could exercise under supervision while emphasizing balance work to prevent falls. We also had a broader program called Exercise Is Medicine. I would always remind patients of the benefit of working out with someone else to aid accountability while serving our social nature. I challenged our patients for those that would listen to ultimately put the twist on cancer by getting stronger through the course of treatment. This surprising and confoundng act would greatly arouse their inner courage to become their future healthy self.




S is for SLEEP


Sleep is KING. The general population is starting to understand the importance of sleep as more people get fitness monitors and the lay press generates stories on the significance of this neglected past time. I try to remind patients that their cancer treatment is their own”Su- per Bowl” and optimal preparation of the body through restorative sleep is critical. I tell them that deep sleep generates growth hormones and sex hormones that foster recovery and is necessary to clear the brain’s toxic buildup.

  • I try to steer them toward non-pharmaceutical sleep aids given the data that most pharmaceutical options reduce deep sleep, become habit-forming, and have significant memory-impairing hangover effects.
  • I encourage patients to stay on a daily rhythm by exposing themselves to sunlight in the morning.
  • Avoid sleep during the day (other than a short nap) to prevent walking the floors at night.
  • Since most patients on treatment become magnesium deficient, I strongly encourage them to take a moderate dose of magnesium in the evening in the range of 400 to 800 mg which may help their sleep and bowel elimination in the morning. See my other suggestions on sleep. I frequently revisit this topic to make sure they're sleeping well through the treatment period.
  • I encourage patients to try to avoid unnecessary adjunctive medications (like casual use of steroids to prevent nausea while preventing sleep the same night) that disrupt sleep. There are many ways to prevent nausea without inducing a state of cortisone driven fight or flight that disrupt sleep, irritates gastric mucosa, weakens immune function and raises blood glucose level and other proliferative markers.
So I remind patients that; "sleep is the most important thing not to screw up during treatment."




I is for INTENTION


A daily exercise of visualizing themselves, with someone they love, looking good and feeling tremendous in their favorite place in the future.

  • I remind them that all victories start in their head with thoughts and intentions. I encourage them not to use angry or perverse words or concepts such as “kill or fight cancer," as these can be contorted with setting intentions.
  • I encourage them always to put the thoughts and images in favorable terms that cannot compete against themselves or anyone else.
  • I suggest they create this original mind video of their fun movie and marinate in it as their first thought in the morning and last thought before going to sleep, and anytime they feel worried or fear coupled with steady nostril breathing.
I confessed to them that anything good that has ever happened to me started with a dream or stretch story and that this tool is used frequently during their treatment. I acknowledge to them that it sounds unscientific, but creating the future vision they want to have is necessary and needs to be coupled with the additional realistic steps incorporated in the BIG SIX.




X is for EXTREME LOVE


Men sometimes retract when this final concept comes up, but women are right in step with me as they know that the most potent force we have in our lives is love. Just like when I ask patients to identify their purpose, generally it is rooted in love. I remind them that difficult and monumental achievements require motivation and power that can only come from love. I put this concept on the table so they can go right to work on a transformation if necessary or maybe just upgrading the emphasis on love in our daily actions. I point out that it is nearly impossible to have fear or anger and love at the same time and which would they instead spend time with. Most cases of remarkable recovery involve some sort of profound personal change (Radical Remission by Kelly Turner). I even go to the point where I suggest that the best predictor of a long-term survivor is one who generates the capacity to get outside of themselves during the problematic cancer treatment and help someone else. Many stories of survivors show a common trait that the circumstances required them to step in and take care of someone else, so they were no longer a victim and became a caregiver (Deep Survival by Lawrence Gonzalez). I encourage the patients to fall in love with their loved ones again, with their acquaintances, and with the strangers, they meet at the checkout line at the grocery store. Once again this sounds flakey and I'm good with that, but there is emerging science that suggests there is intricate communication between cellular mitochondria initiated by our intentions and emotions. After the BIG SIX discussion, I make sure I walk them to the checkout region near the front of the cancer center, reestablish our next visit and with a handshake or a hug wish them well and then remind them that “they will be fine, and they won't go through this alone."