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

Ingest Real Food


Okay so we have established baby steps number one (Ingest real food); consider a low carbohydrate diet-high fat diet when one embarks on a cancer treatment program. This low insulin stimulating diet will serve to lower inflammation, blood glucose levels, and can put some strain on the mutagenic cancer cell population which is dependent on glycolysis or fer- mentation in a low oxygen environment for the production of energy. This glycolysis pathway production of energy only produces two ATP (Energy currency in the body) while generating reactive oxygen species or ROS that the detoxification pathways in the system need to manage. So a low carbohydrate-high fat diet is the first baby step.




Fasting


The second baby step incorporates a version of intermittent fasting before each radiation or chemotherapy treatment. This sounds contrary to standard medical recommendations as suggesting that a cancer patient not eat sounds heretical. The biochemistry around fasting supports everything the body needs to clean up cells at risk for a mutation (autophagy), well-reactivating detoxification pathways and healthy stem cells which is precisely what the body needs during treatment. There is extensive indirect evidence shy of a randomized placebo-controlled trial that metabolic priming with 12 to 14 hours of fasting before treatment enhances the cytotoxicity of the radiation and chemotherapy while improving the resiliency of normal cells to these treatments. So in short, the treatment works better with less side effects. As mentioned above, one can modify it by drinking Black coffee or coffee with clean fat in it or some substitute drink that does not bump any insulin levels and contributes carbohydrate to the system. The morning rehydration step with salt water will not interrupt the fasting as well, and by all means, come in maximally hydrated (as determined by high clear urine volume and your daily weight measurements; remember you are your own best doctor :-)). So don't worry if your treatment is midday and you haven't eaten since dinner the night before, increase your hydration with your water sea salt mix and march forward. I look at baby steps one and two as simple changes that certainly won't hurt and may help significantly and most caregivers will be on board with even if they don't subscribe to metabolic strategies.




Be Your Own Doctor


The third baby step involves stepping up as your “ own best doctor” and measuring blood sugar and ketone levels (the breakdown product of fat metabolism and precursor for efficient energy production) analytically before each treatment. I indeed foresee that someday metabolic clinics will incorporate this into their protocols as it is quite easy to do. In the last two years, a product has become available that measures both blood sugar and blood ketones in the same unit. The Keto-Mojo is reasonably priced under a hundred dollars and easy-to-use with good videos online. This step allows the patient to verify better that indeed the blood sugar is lower and ketones are going up as one would hope 12 to 14 hours into the fast before treatment. There is excellent support to suggest modest low ketone levels of 0 to 2 in the blood have some benefit during treatment. There is an index (Glucose Ketone Index) that was created by Dr. Seyfried to set targets that reflect a level of low glucose and high ketones levels that in his extensive work should predict a therapeutic effect. If the GCI is < 3 on the index (versus just a tumor sensitizing and normal tissue protective effect), there may be cytostatic and cytotoxic effects. One can calculate the index by taking their blood glucose level and dividing it by 18 to get it in mmol/l units and then dividing by the ketone level in the blood which is already in mmol/l to get the GKI or Glucose Ketone Index. So if one is on a fast and has blood glucose the 55mg/dl and a ketone level of 3 mmol/l the index becomes approximately 55/18 divided by 3 or about a GKI of 1. This would be a level that reflects moderate ketosis and result in a therapeutic effect. A rough predictor of degrees of ketosis based on the GKI are the following: <3 = high ketones therapeutic ketosis, 3-5 GKI level-moderate functional ketosis, 6-9 GKI level-low ketosis and >9 GKI - no ketosis. If one were driving for metabolic priming before treatment, they would try to get a GKI of less than 5 for as many procedures as possible, and that would significantly impact the therapeutic ratio or in simple terms probability of eradicating the tumor with lower normal tissue side effects. Sounds like a pretty good deal; I'd buy a tool for 100 bucks including the measurement strips, save money by not eating as much, and significantly improve the likely success and tolerance of an expensive one opportunity treatment course (and maybe correct some other metabolic conditions also present independent of my cancer).




Theraputic Effect


The 4th baby step is the addition of exogenous ketones by mouth to enhance the ketosis and thus the therapeutic effect. One is fostering ketosis when they take in coconut oil, grass-fed beef butter, and other clean fats, as these have ketones precursors in them. Ultimately one targets one some form of Beta Hydroxy Butyrate (BHB), Acetoacetate, Mid-Chain Triglycerides that feed into the energy pathway (Krebs cycle or TCA cycle) without going through glucose and produces 34 ATP or energy units requiring approximate 30% less oxygen with fewer damaging by products (ROS). There are numerous sources of exogenous ketones that have come on the market in the last three years. Some are capsules you can take by mouth while others are powder mixes that taste like sports drinks and then others mixes that are added to smoothies like protein powders. These can be purchased at health food stores or online so pick out a product that Is convenient and tastes good and experiment with blood glucose and ketone blood levels to measure its impact. One can generally tell if they’re in ketosis from fasting plus or minus addition of additional ketones by a dry mouth, mildly bad breath, steady energy, clear thinking and absence of food cravings. I have used many products but stay with Brain Octane capsules and liquid by Bulletproof to get the pure form of MCT (only contains C8 chain MCT which is pure ke-tone), and Real Ketones Capsules and Keto Meal powder by Kegenix. Once again there are more and more products being developed every day so shop around.




Lowering Insulin Messaging


The 5th baby step is a little more interventional, but in many patients, there is an opportunity available. This, of course, assumes you initiate the first three baby steps but by this fourth step, you're taking it to a higher level while on your traditional cancer treatment course. This step will require a discussion with your family doctor and oncologist. I strongly suggest that all the steps are discussed with your oncologist but remember you're your own best doctor and if shared decision-making and honest discussions are not an option in the clinic you attend, you may be working with the wrong doctor. This step involves adding a medication that enhances and mimics a low insulin environment and further supports and improve therapeutic ratio or simply said again; greater tumor eradication with lesser side effects. Many patients may be on metformin, and I usually encouraged them to stay on this and possibly even increase the dose if they can tolerate it. I invited them to check this out with the family physician and explain that it has beneficial effects in the outcome of the treatment of cancer. At first, when many patients were found to have better results if they happen to be on metformin, investigators thought maybe it was the lower insulin levels through its mechanism of increasing insulin sensitivity in the body. Currently, another mechanism of action identified through the impact on intracellular proliferation pathways (mTOR, AMPK). The other medication that has similar serendipitous benefits when someone is on cancer treatment is Lipitor/atorvastatin. This also has intracellular antiproliferation effects and has been found to improve outcome in many historical trials on a variety of different cancers. Both these medicines have a relatively low side effect profile in standard doses ( metformin 5-10% get diarrhea, atorvastatin possible muscle cramps, and liver function changes) and could be added to a patient’s medication list just before, during and for a while after the treatment course or if there're already on them just continue them. These are prescription medications, and while some supplement options have supported similar mechanisms of action (Berberine for metformin, Red Yeast Rice for atorvastatin), they have never been tested or identified in studies to have a clinical impact similar to the actual prescription medicine. One other product that is still in the experimental stage but could be used in cancer management to enhance the effect of the ketogenic diet is 2-deoxyglucose or 2-DG. This product competitively inhibits the glucose burning pathway and thus puts pressure on tumor cells that have limited or no energy production through fat burning pathways. 2-DG has shown fantastic results in the laboratory, has an excellent safety profile but is not commercially available at this time for patient use. I know in today's world the bright patient may say I can get these without a prescription online, but I encourage you to work with your physicians and be careful of anything purchased on the Internet. Any pharmacy used on the Internet should have consumer lab testing verification stamp of approval.




Adguavnt Metabolic Treatment Protocol - COC Care Oncology Clinic


The 6th baby step is really an extension of the fifth but in a more formal and committed way. Once again I would encourage everyone to participate in step 1,2,3 and all the other suggestions. There is a Company called COC for Care Oncology Clinic of the United Kingdom and is a subsidiary of SEEK Pharmaceutical. COC was created through the work of Ph.D. pharmaceutical researcher Robin Bannister who was desperately seeking options for his wife with stage 4 ovarian cancer. Robin used artificial intelligence to screen the world's literature for evidence of anticancer effects with the existing, time tested older generic medications. Initially, 100 medications showed activity, and they weaned it down to 10 and ultimately 4 to create the Metabolic Protocol. These “ repurposed “ medications are safe and well tolerated and add minimal cost to the monthly care of a patient. The COC was created and initially treated 99 patients with glioblastomas of the brain which were being processed with the standard of care (surgery, radiation, and oral chemotherapy generally leading to a median survival of nine months on average) in the UK. These patients were treated adjuvantly which means they were given the treatment along with the standard procedure and many of them started it midway into their treatment or later in their treatment. These four drugs included previously discussed metformin and atorvastatin and two other medications (doxycycline and mebendazole) that are cycled in a specific way, so the patient is really only taking three additional medicines at one time. The patients were followed for the outcome, and those on the Metabolic Protocol had a tripling of the median survival compared to historical controls which quickly caught the attention of many researchers. This protocol experience and outcome is pending publication. Since these results were identified, the Metabolic Protocol has expanded to over a hundred hospitals in the UK, and it is used for many high-risk cancers in addition to brain tumors in an adjuvant manner. This adjuvant protocol allows patients to get the standard treatment for their cancer plus the Metabolic Protocol along with it and their data is captured by the company and outcomes monitored. There is much excitement about remarkable findings with this combination in many types of cancer. Those interested in the Metabolic Protocol in the United States can now find their virtual panel of an oncologist for a small fee to access the protocol and delivery of medications. Once again I strongly suggest working with your physician in a shared decision-making manner and commit to lifestyle changes as discussed above and don't just concede to taking additional medicines alone.




Hyperbaric Oxygen Therapy


The 7th baby step means you're really ready to jump in with both feet. Earlier, I spoke about nostril breathing as a tool to better deliver enough oxygen, keep one in a parasympathetic balance, keep blood CO2 levels high enough to let the oxygen best get delivered at the microcirculation level. Further, in the discussion we talked about how cancer cells thrived in higher glucose and lower oxygen environment (fermentative metabolism). We spoke about ways to reduce the blood glucose and manipulate the body to favor fat metabolism and thus destabilize the cancer cell population while vitalizing the normal cells. We also know that normal cells prefer and thrive with oxidative metabolism (34 ATP per glucose input) or high oxygen environment at the tissue level (very efficient if using fat generating ketone substrates) and there are also ways to manipulate this strategy. What I am referring to is the use of Hyperbaric Oxygen Therapy (HBOT) or other strategies to drive oxygen into the microcirculation. Hyperbaric Oxygen Therapy is best known for the giant steel chambers that deliver pure oxygen greater than 2 atmospheres under strict medical supervision typically in wound centers at larger hospitals. There are approximately 14 medical indications for this hospital-based therapy where an individual gets 30 to 60 treatments or “dives” generally for 60 to 90 minutes each. The typical indications are severe non-healing wounds, necrotic bone sites, post surgical/radiation wound healing failures especially in the mouth with a risk of bone necrosis of the mandible. These treatments are quite expensive and generally run over $50,000 per course and thus require Insurance coverage to consider. A lighter version through soft chambers that deliver pressures under 2 atmospheres and only use nasal cannula oxygen supplement without pure oxygen is much more available for the average patient. These soft chamber centers are becoming more available in larger cities, and some patient rent a chamber or buy one to use before, during and after their treatment to intensify the therapy and catalyze the recovery. Generally, the patient would engage a 60 to 90-minute hyperbaric session within an hour before or after the radiation or chemotherapy treatment. There are many patient outcome studies in the literature where this has been used but never in any phase three randomized trial to justify placement in the current US treatment guidelines. Dr. Thomas Seyfried and Dr. Dominic D'Agostino have extensive work in animal models showing remarkable synergy with Ketogenic Diet Strategies (KD) and even more synergy when radiation or chemotherapy is added to the diet and oxygen therapies. There are new tools that might offer similar benefits of elevating hemoglobin and plasma concentration of oxygen identical to HBO, but these are less available less studied. One novel product is called LiveO2 which puts a person on a stationary spin bike and starts them off breathing room air, and after a few minutes, they flip the switch and change the input into their breathing mask to lower oxygen air mix of approximate 10% versus the normal of 21%. As they struggle to maintain a pace, their body triggers all the biochemical microcirculation strategies to maximize blood flow, and oxygen uptake and the mitochondria likely get the message to become more efficient. After a period of struggle on the protocol and of course dependent on the fitness of the individual, the rider then flips to pure oxygen and gets maximum delivery of oxygen as the body is primed for maximum uptake. The rider does a few cycles of this to get the best effect. Currently, protocol experiments are using this Live 02 System in the management of stroke patients, PTSD patients, concussion victims, and more; all similar to what HBOT is used for his well. Another potential strategy that targets enhanced oxygen uptake in the microcirculation as one of its effects is Ozone Therapy. This is challenging to administer as breathing it is dangerous and could be damaging to the lungs and possibly lethal. Typically practitioners will bubble ozone through the patient’s blood when it is outside the body and then redeliver it, or administer it by transrectal or transvaginal routes. An expert in this is Frank Shallenberger MD for further research.





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