NBT People: Integrative Oncologist Stacy D’Andre, MD [transcript]

Written by Christopher Kelly

Oct. 11, 2019

[0:00:00]    

Christopher:    Stacy, thank you so much for joining me at my Bonny Doon recording studios. I very much appreciate you driving all the way down from Sacramento. Thank you so much. 

Stacy:     Thank you. 

Christopher:    We're going to go and see the beach. 

Stacy:     Yeah. Sounds good. 

Christopher:     Stacy is an integrative oncologist. Do you agree with that? 

Stacy:     Yes. 

Christopher:    You're a lot of things, but that's one of them. 

Stacy:    That is one of them currently, yes. 

Christopher:    And Stacy is a doctor that we've been working with. How long has it been? It's been a couple years now, isn’t it? 

Stacy:     At least three. 

Christopher:    Okay. And you’ve worked with Megan and my wife, Julie. 

Stacy:    In the beginning. 

Christopher:    I noticed that Julie -- yeah, in the beginning -- was the one that initially talked to you about your diet.

Stacy:    That's right. Correct. 

Christopher:    And I think you've also talked to Zach about strength and conditioning?

Stacy:    I worked with Zach. I worked with Simon a couple times. So the whole crew. 

Christopher:    Let's start by talking about your identity as a skater. 

Stacy:    Sure. 

Christopher:    So how did you get interested in skating? When did it happen? Who were you with? What was going on? 

Stacy:    So I started skating when I was probably around 10. We had a rink down the street from my house and started taking lessons. I skated for a few years, didn't really go very far with that and went on to college and med school. They opened a rink in Virginia when I was doing my residency, and I decided to take it back up as an adult. So I started skating when I was about 28. I got really into it. I was competing and I did that. For a while had a couple kids, took a break, and then started back up when I moved back to California and started competing again. So I was training pretty hard for a good eight years and skating pretty much every day.

Christopher:    Can you just describe the demands of the sport? 

Stacy:    Oh, it's very demanding, especially as you get older. You're still jumping and spinning, and you need huge amount of core strength. But it's also artistic, so you're skating to music and working on routines. It's an interesting demand on the body because you have to have these high energy bursts where you're doing a routine for maybe two and a half minutes, but it's like, literally, doing jumping jacks on the ice as you're going through, and then you're trying to look pretty and smile at the same time. So it's a really demanding sport, but I really enjoy it. I'm still on a break right now, but I'm going to go back. That's typical of adult skaters. Life gets in the way because -- if you're not skating at least three or four times a week, you can't keep up. 

Christopher:    Okay. Have you got access to an ice rink now?

Stacy:    I kind of do. There will be one opening next year closer to my house, so I'm planning to go back next year. 

Christopher:    Okay. And what's it like having somebody judge you? I have always wondered about that. 

Stacy:    I've done a lot of things in my life in terms of tests and speaking and lectures. I can tell you, being in front of an audience skating when you're the only one out on this huge rink or people are judging you, there's nothing more fear inducing. I’d rather talk in front of 500 people than be out there by myself in front of six judges. 

Christopher:    So how do you handle that? 

Stacy:    Not well. 

Christopher:    How does anyone handle it?

Stacy:    When I was preparing for my competitions, I would do a lot of visualization. So I would run through the routines at night kind of in my head. I listen to almost like hypnosis tapes to try to keep myself calm. I think it might have helped a little bit, but it's really hard to control your nerves. 

Christopher:    So have you ever had any disasters on the ice where you're like…?

Stacy:    I don't perform as well when I'm under a lot of pressure. I always feel like I could have done better. So it's something that I've always struggled with. And if I go back to it, I'm sure I will struggle again. 

Christopher:    Do you ever notice the other end of that spectrum? So when working with clients, we see this quite a lot and it applies to all sports. Maybe you could say there's an analog arousal scale where zero is I'm asleep and ten is this is the Olympics and I’m under way too much pressure. It seems like you can have the opposite problem where you just don't have enough arousal, and then you start making mistakes just because you're not really paying attention. 

Stacy:    Right. Yeah, I never was like that. I was always a ten. 

Christopher:    You're always at ten. You sound like my Australian cattle dog puppy, like there is only ten.

Stacy:    There is only ten when it comes to skating. 

Christopher:    That's amazing. So tell me about how you're eating. When you first started skating, how was your diet compared to what it is today? 

Stacy:    So I thought I had a decent diet back before I developed an illness. I was just eating yogurt and probably quite a bit of processed foods. I wasn't eating organic. I would eat just pre-packaged salads. I did eat some veggies. I ate a lot of meat. I was drinking a lot of wine. I just kind of not really paying attention, I guess. It was more I have to feed a family and whatever is, you know, I have a lot to do, so it was more out of convenience than anything. But I really had no education in what I should be eating. Even going through med school, you think I would know something. Well, not necessarily. They don't teach you much in medical school. So not a great quality diet at all. 

[0:05:06]

Christopher:    Okay. Do you think that's typical of doctors? Do you think they all don't pay that much attention? One of the things I've been thinking about a lot recently is that what is it that constitutes something that's worthy of my attention as a doctor? I'm talking in terms of somebody else's voice here, like is diet worthy of my medical license?

Stacy:    I don't think so. I think most docs are trying to get through their day. 

Christopher:    Oh, really? 

Stacy:    Yeah. 

Christopher:    They’re not even paying that much attention? 

Stacy:    I don't think so. In my experience, no. People are struggling. Doctors are struggling right now in terms of burning out. There's so much work that needs to be done. We're on the computer, doing our charts well into the evening. So there's so much more work put on us now that I think people are struggling just to get through their day, and let alone try to find space for exercise and time for yourself and then actually working on diet as well. I don't think that's happening. 

Christopher:    So what happened to you? What was the tipping point that brought you to NBT door?

Stacy:    So I had just come off of an adult national competition, and I really wanted to try to take a step-up in terms of my performance. I was working on some double jumps at the time. We have a harness structure, a harness where they put harness and it allows you to do the jumps with assistance. 

Christopher:    That's amazing. 

Stacy:    Yeah, so they pull on the pulley and lift you up, so you're able to do the jump and then not kill yourself. So it's a safe training space for adults. But I always struggled with jumps. I always struggled with that fast motion. 

Christopher:    Yeah, the explosive power.

Stacy:    The explosive power always --

Christopher:    Which is where Zach comes in, right, with the strength and conditioning?

Stacy:    Exactly. So I always struggled with that, and I wanted to try to kind of take that to the next level. I started working really hard. I also, at the same time, kind of got myself into a keto diet. I thought I'm going to try this and see what happens because I just had been hearing a lot about it. Initially, I felt really good on keto, but then after about a month, I started feeling really bad -- super low energy, had no power on the ice whatsoever. I had lost a few pounds, which I was trying to do because every pound counts when you're trying to get up into the air. At that time, I went in and my thyroid function was just not good. So my thyroid had kind of gotten trashed. 

    I had been on taking Synthroid for 25 years for Hashimoto's. So it was just like a stable dose of that, but it wasn't working. That's when I hooked up with you guys to try to figure out what is going on with me. I just kept getting worse, and regular doctors really had nothing to tell me. 

Christopher:    What did you think was going on? 

Stacy:    I had no idea. I mean, I knew --

Christopher:    Particularly with the diet, what do you think -- so the ketogenic diet shouldn't do that on paper, right? And it's not been a typical experience. So why do you think you were different? 

Stacy:    I think probably what happened was I had a big shift in maybe my gut microbiome, or possibly I was getting endotoxemia possibly from the high fat. 

Christopher:    You felt terrible?

Stacy:    Oh, I felt terrible. After about a month or so, I felt really bad. I think there are some people probably that just need a little more carbs if they're trying to do explicit work and, obviously, I did.

Christopher:    Do you think there isn’t enough food that's like the number one suspect?

Stacy:    Maybe not at the time. I may not have been eating enough. But then whatever happened with my thyroid, I don't know if it was related or not to the keto diet, I know you can have thyroid changes on keto diet. That is something that they monitor in children who are on keto. So who knows if that got -- if that was part of it or not?

Christopher:    And what’s the diet you settled on now?

Stacy:    So now, I am mostly plant based. 

Christopher:    Oh, really? 

Stacy:    Oh, yeah. Mostly plant based. Sometimes I'll eat grass-fed chicken or beef.  I try to get as good qualities I can. I eat eggs. The majority of what I eat is vegetables.

Christopher:    Okay. Yeah, that's true of all diet too. I'd say that if you looked at our plate, usually, especially at dinnertime, the majority of it -- and lunch actually for that matter too -- the majority of it is covered in plants, but there's still a significant amount of protein. We're definitely getting adequate protein in our diet. 

Stacy:    Yeah. I eat tofu. I'm making sure that I get protein with every meal. So that's kind of where I've settled out, and I feel good. Like for me, this diet seems to work well for me. 

Christopher:    And is it being influenced by your training at the IFM and your work as an integrative oncologist? 

Stacy:    Yes, definitely. Yes. So as I've learned through my coursework, all the benefits of a plant-based diet in terms of phytonutrients and all those things, yeah, definitely. 

Christopher:    Yeah, I find the evidence for the microbiome quite compelling and maybe short-chain fatty acids are a good thing. And you generally don't get those fermenting meat. 

Stacy:    I don't think I had any of them when I did my testing. 

Christopher:    Oh, yeah. Okay. 

[0:09:57]

Stacy:    My gut, if you remember, my gut was an absolute mess. I've gone back because I didn't really know what that meant but now I do, and I went back and looked at it and I was like, wow, I was a mess. It takes six to nine months to get better. 

Christopher:    Yeah. Tell me what you've learned about essentialism. What does that word mean to you now? 

Stacy:    For me, that book was pretty life changing.

Christopher:    We're talking about Greg McKeown's book.

Stacy:    Yes. So that was recommended to me by Simon. I met with Simon because I was struggling with -- as my health was getting better and I started taking courses through IFM and really saying, wait, there's more to this training and I would like to start bringing this into my own practice. So as I'm talking with Simon, we discovered that I was doing just doing way too many things. Many of the things I was doing I really didn't like. I was doing a lot of side projects and research and a lot of administrative work. And that book really just taught me, you've got to pick the things, the very few things that are the hell yes. This is what is firing me up and just let everything else go. 

Christopher:    Right, right. The alternative is -- I think it's Greg McKeown that says "a millimeter of progress in a million directions."

Stacy:    Yes, exactly. So I did and I started focusing on starting a new practice. I finished all IFM coursework. I let go of a whole bunch of things that I was doing, and I was able to then focus. I'm a million times happier. So that book was really life changing.

Christopher:    That's wonderful. Did any of the bad things that you thought -- I mean, so you must have some belief that prevents you from letting go of all of these things, right? So maybe you're on the board of some advisory committee or something administrative, and you're worried that if you step down as chairman of that, then everything's going to go to hell in a handcart. Did any of that turned out to be true? I mean, maybe that's what needs to happen in order for Stacy to be the best version of herself. 

Stacy:    Right. I think it's a fear of missing out. For me, that's what it was, a fear of I'm going to miss out on something important, or a feeling of obligation, like I'm the only one who can do this when in reality that's not true. There's always someone there who can pick up the pieces and there was.

Christopher:     You have to be actively irresponsible.

Stacy:    Pretty much. One of my partners, she just said, "I'm really interested in research. If you don't want to do that anymore, I'll take it over for you." So everything just really worked out well. I still am the chair of the department. I haven't given that up yet, but it's kind of on everyone's radar that I'm probably going to step down at some point because I need to focus even further. So it'll happen.

Christopher:    Talk about your career change and how important that's been to recovering your health. This is generally the hardest thing, right? When you're working with clients, sure, I can fix your diet, no problem. We can talk about sleep hygiene. We can talk about the way that you move and how much you're drinking and some stuff related to stress management. But we've seen it many times now that you get support, and you realize that your job is actually the last thing that's holding you back. And the reason it's still here holding you back is because it's the hardest thing to change.

Stacy:    Absolutely. I think what happens with a lot of physicians is you get stuck. You're in a job, you've trained for so long, and what else can you do? Especially when you're a sub-specialist, and I was a sub-sub-specialist, so I did GI cancers and gynecologic cancers. That was kind of my niche. So I didn't even do general oncology. I was super focused. So if I don't do that, what am I going to do? 

Christopher:    I think they call that [0:13:55] [Indiscernible]. 

Tracy:     Yeah, 100% Yeah. So I had invested so much into this, but then I really wasn't happy. I felt like I was doing the same thing every day. I'm giving chemotherapy, I'm kind of seeing the same results, didn't feel like I was making a difference. As I went through my coursework, I just became interested in the gut microbiome and what does that mean? And then how can I incorporate that into the care of cancer patients? So every course I went through, I pulled out little pieces that I could incorporate into my practice. It was this like two-year process of figuring out, I want to do this. This is meaningful to me, and I think it's going to be more meaningful for my patients. I met with administration and told them what I would like to do. They were, surprisingly, I'm totally on board. 

[0:14:52]

Christopher:    That's amazing. That's amazing. Good for you. I wonder about that. I think it was in Dan Hurley's book I read recently, I think it's called payoff. Maybe we could link that in the show notes. But he talks about that, how you can really kill motivation by having people do tiny repetitive tasks and never seeing the big picture. So I think maybe it was Karl Marx that first described this model of the pin factory. I'm the guy that puts the head on the pin, but I never see the finished pin. I put the heads on all day long. 

Stacy:    Yeah, yeah, exactly. 

Christopher:    That really kills motivation. I wonder if that describes you as the oncologist that works on the gut. I just see this tiny little part of this human, and there's a whole human there that -- 

Stacy:    There's a whole person there. What I've noticed, as I've switched over to a more functional approach to medicine, before I would see patients and I would see someone who like, let's say they had colon cancer, and I would see the patient and, oh, well, this patient has colon cancer. I have to do X, Y, and Z to treat the cancer -- chemotherapy, radiation, whatever. And that's fine. It's very narrow, superfast visits, 15-minute appointments just to go through chemotherapy side effects, blah, blah, blah. But now I see someone who comes in with colon cancer, and I see the whole person. I see a person who is stressed, who isn't sleeping, who isn't eating well, who's worried they're going to die, who has a family who's stressed out because their loved one is sick. I see a whole picture there as before I was just seeing this little piece of a person. So personally, for me that's been transformational.

Christopher:    I'm sure. So describe what happened before then. So what was the standard of care before when that person came in with colon cancer? 

Stacy:     Well, mainly, you see them, you figure out what stage they have. They probably already had surgery. And then you decide, is it appropriate for them to have chemotherapy to reduce their risk of recurrence? So if they're stage three or whatever, if they're stage four, then they are all treated with chemotherapy. So you basically decide what treatment you're going to give them. Are you going enroll them in a clinical trial? What are you going to do? And that just starts the ball rolling. 

Christopher:    Okay, so there's never any discussion of diet or exercise?

Stacy:    No, no, no. So they're on their path, and they're doing their chemo or whatever. If there comes a point where they're finished, like, let's say, they have stage three and you finish their chemo six months later, then they're kind of done. They're in remission and they're kind of just set loose, and patients don't know what to do. They've been on this roller coaster, and all of a sudden the ride stops and they're like, "Okay, now what do I do?" And the doctor says, "Okay, we'll see you back in six months."


 

Christopher:    All right, hurry up and wait. 

Stacy:    And then they don't know, what can I eat? Should I exercise? What supplements are safe? What can I do to help prevent a recurrence?

Christopher:    So the patients are thinking like that. 

Stacy:    Oh, they do. 

Christopher:    They do think that their diet has something to do with the problem.

Stacy:    Yes. 

Christopher:    So they just don't know what to do. 

Stacy:    They don't know what to do. In my practice now, I ask people, I ask every single person, why do you think you got cancer? It's part of my intake form. 

Christopher:    Okay, and what did they say? That's a fascinating question, isn’t it?

Stacy:     Yes, I'm tracking it. I've seen over 200 people now since I started. The number one answer is stress. 

Christopher:    Oh, really? That's a very sophisticated point of view to think that your emotional and psychological stress could somehow -- I totally agree with them. I'm just surprised at the sophistication of the answer. 

Stacy:    I see it again and again and again. Women, men, old, young -- stress. Then the second thing I see is diet. That's lower down.

Christopher:    People are right. I'm surprised that, you know, I thought that they would say things like, "Well, I think that when I was younger, I smoked some cigarettes and maybe I got exposed to radiation."

Tracy:    There's a few. There's a few of those, but by far and away, it's stress, diet, and then there's a few people that will say like a toxin. They thought they were exposed to a toxin, or there's a very few percentage that say genetics. I have a strong family history. But then they'll also write next to that, they're write, but I drink a lot, or I had a poor diet. So people, they are, they're very sophisticated. But that's the number one thing is stress which is fascinating. 

Christopher:    That's amazing. So how did you convince the officials -- it's at Sutter, isn’t it? 

Stacy:    Mm-hmm, yes. 

Christopher:    So how did you convince them that any of these -- my experience, I mean, I don't want to sort of throw Sutter under the bus, but it was Sutter that I went to see when I saw a gastroenterologist many years ago, and they told me it has nothing to do with my diet. I have no idea whether that's like a kind of general viewpoint in medicine or whether that's just something that that particular gastroenterologist said at that time. I mean, how did the officials at Sutter -- oh, it's nothing to do with diet. It's nothing to do with stress. Is that the sort of thing that they would say, or they obviously bought into the --?

[0:19:47]

Stacy:    So the way I approached it was I actually started doing some lectures first. I gave a lecture on the role of the microbiome in disease and in cancer. Some of the studies that were coming out at the time were showing that the gut microbiome plays a role in how patients respond to immunotherapy. So what you eat directly correlates with your response to immunotherapy. If you have a high plant-based, high-fiber diet, you're five times more likely to respond to immunotherapy. 

Christopher:    Interesting. So you actually got data on this stuff that you could --

Tracy:    Yes. So I did lectures. I showed them studies on probiotics. So probiotics during chemotherapy and radiation have been shown to reduce the risk of severe diarrhea and it's safe unless you're severely immunocompromised. So as I'm showing them evidence-based medicine, people are starting to get interested in it. I kind of pitched it like, look, this is a missing piece of oncology care where our patients are taking supplements anyway and many times it's not safe. There are many interactions with supplements and chemotherapy.

Christopher:    Right. Oh, God, I would never mess with that. 

Stacy:    An example is probiotics and immunotherapy. So if you're on immunotherapy --there was a paper out of MD Anderson showing, if you're on a probiotic, you have a lower chance of responding. 

Christopher:    Oh, wow. 

Stacy:    Because that's affecting the immune system from the gut, right? So it's teaching patients and teaching other doctors the safe use of supplements. A lot of times what I do, that's what I spend a lot of time on is like, no, don't take that. That's not safe to take right now. Let's take it when you're done with chemotherapy.

Christopher:    Okay. I'm just trying to get my head inside of the decision makers at Sutter. What were they thinking? Are they thinking, well, we think this is an important determiner of patient outcomes, or are they thinking, well, the patients are worrying about this anyway, so somebody should be talking to them? 

Stacy:    There's a patient demand. 

Christopher:    It’s just a patient demand. 

Stacy:    It's a patient demand. I'll give an example. We have an integrative department already practicing, so integrative medicine in the Bay Area and also in Sacramento. Their focus is not cancer. Their focus is just general population. But they had a waiting list of 1,000 patients. You can't get into see their physicians. They're recruiting like crazy because there's so much demand for people to have a different approach to their medical care, not just going in and saying, "Hey, give me a pill for this problem." "Okay, fine, I'll see you when I see you." They want something different. So I think that would have been a harder pill if it weren't for the integrative department because they kind of set the stage for me to come in and do similar work but just focused on cancer patient.

Christopher:    Right. I have to say, this is quite a compelling argument for the US system, isn’t it? I don't really have many good things to say about the US healthcare system, but this bottom-up market-driven approach to patient care has got something to say for it, right? Whether you look at like a nationalized system in the UK where it's more of a top-down approach, we're going to decide what's best for you as the nation and the patient doesn't really have much to say about it unless you go private, right? 

Stacy:     Unless you pay for it. 

Christopher:    You can do that. It is an option in the UK. That's interesting, isn't it? 

Stacy:    Yeah. 

Christopher:    So what do you do for all these people that are totally stressed out? Again, like one of the hardest problems you could possibly solve.

Stacy:    Well, we talk a lot about where their stress is coming from. I spend a lot of time with people. 

Christopher:    It's easy for you to empathize with those people because, hell, I was you. 

Stacy:    I've gone through many of the things that they are going through. I think validating their concerns that, hey, I think the stress was a part of what led me to develop cancer. I'm validating that also. I'm saying, yes, I believe you. But now, we need to work on ways that we can reduce your stress because I don't want you to get something else, another disease or have your cancer recur. So I tell everyone about calm and headspace. We have mindfulness classes that they can take. We have counselors they can be referred to. So obviously, I'm not a counselor, so I can't spend that type of time with them, but getting them the resources that they need to start really working on stress reduction. And people do. They do work on it because they realize how important it is. 

Christopher:    It's really high stakes at that point, isn’t it?

Stacy:    It is very high stakes. And people are motivated to change. They're motivated to change their diet and their lifestyle. You wouldn't believe some of the turnarounds that I've seen, unbelievable. 

Christopher:    I think we made a key distinction here, and it was really Simon that brought this to my attention first. You've just talked about two types of stress mitigators, right? So you talked about Greg McKeown and essentialism, and what that's doing is taking on the stress at the source. I'm just going to cut this thing out of my life, and it's no longer going to have an impact on me. But then something that you just talked about then, mindfulness, so this is what you might call it, an emotional type coping strategy that's dealing with the problem, the target. There are two things there. I can deal with it at the source, or I can deal with the target. 

[0:25:14]

    Simon was definitely the first person to point this out to me. So the thing is that most people, they have a gross imbalance of one or the other. So you have fantastic emotional coping skills but none of the task-based stuff, right? You weren't cutting the appropriate things. So is that something you talk -- so my point is here that the true stress ninja has both. They do both. Is that something that you've talked -- do you talk to your patients about essentialism?

Stacy:    Yeah, I've talked to them about it, and also what I've learned from my patients, many people, no one's really stuck ever, but sometimes people feel like, I'm providing for a family. I have to do this job that I have. It's very stressful. So there are situations where they can't get out of a situation, even though it's a one or two on their essentialism list, they can’t just cut it out just because of financial issues, or maybe they need health insurance, right? 

Christopher:    Right. Well, yeah, I mean, of course, there's always the controllables and the uncontrollables. So you control the controllables and then accept the rest. 

Stacy:    And so accepting it, though, is where you can also focus a little bit in terms of that's where the meditation and mindfulness comes in. It's how you're responding to what's happening to you in the external world. 

Christopher:    Yeah, absolutely. I feel for me, like the mindfulness, whatever you want it, however you achieve that, just noticing with flexibility and curiosity, it gives you the opportunity to notice how you're feeling. I noticed that I'm feeling pissed off right now. It's just the active and then you can always thank your brain. Thank you, brain. I appreciate you being pissed off about my financial situation. However, I choose to proceed anyway. 

Stacy:    Right, exactly. 

Christopher:    And it's very difficult to do that without -- lots of meditation is really good for having that sort of way of thinking. Tell me about cannabis and its role in your integrative oncology practice. 

Stacy:    Yes. Being in California, we're lucky cannabis is legal medicinally initially and then recreationally. So I think the western states are way ahead of the rest of the country in terms of using medical cannabis. Our patients have been using it for decades. There are prescription drugs that are used for nausea and appetite. They're synthetic THC which is Marinol.

Christopher:    So why is it still -- so Schedule 1 means no medicinal use, but you just told me that there's a medicinal use. Why it's a Schedule 1?

Stacy:    That one is a prescription, so the doctor is actually writing -it's like picking up --

Christopher:    It’s the same compound there, right? If I can find it in the plant and there's a medicinal --

Stacy:    It’s synthetic, so it’s manufactured. 

Christopher:    Okay. Is it exactly the same molecule or did they --

Stacy:    No, it’s THC, but it's synthesized, and so it's not coming from the cannabis plant where you get a full plant extract.

Christopher:    I get it. I'm just wondering whether they put on a side chain or made it and said, "Oh, no, this is a totally front molecule."

Stacy:    No, as far as I know, it's the same molecule. It's just synthetic. But what we know about synthetic or isolates, they're not as good as when you use the whole plant. So the whole plant extract, you're getting so many more things from the plant. You're getting terpenes and flavonoids. There’s hundreds of compounds in the cannabis plant. Our patients use them for nausea. They use them for sleep, wellbeing. They use them for pain. You can actually reduce the amount of the opioids that you're taking to using medical cannabis. It's very safe. There are some caveats to that. There are interactions with other drugs that you need to be aware of, but for the vast majority of patients, it's safe.

    Initially, I wasn't really into it because I didn't understand it. I didn't know much about it, and I was uncomfortable talking to people about it. But over the years, I've seen the benefits that my patients have from using it, and I started studying it more and more. So I've done courses now and gone to conferences, and now I'm very, very comfortable in talking about different products with patients and the indications for use. 

    The tricky thing is many patients want to know, well, what can I use for my cancer? And that is the big unknown right now because we know in animal models and cell culture models, different strains of cannabis with different, they call them chemovars. It's what's in it -- CBD, THC and terpenes. All of the ingredients is called the chemovar. So the chemovar profile is going to be different when you're treating a breast cancer versus a prostate versus a colon. They all respond differently, at least in animals. 

    So we don't know what to tell people. There's been one study in humans and that was in Europe, and they studied patients with glioblastoma multiforme, so the bad brain tumor, and they were all getting standard of care, so Temodar and radiation therapy for their brain tumor. It was a very small study, only like a dozen people or so on any term. Half got cannabis and half did not. They were using a compound called Sativex, which is a one-to-one ratio THC-CBD. And as an oral mucosal spray, the patients titrated themselves up to a dose that they could tolerate, maximum of 30 milligrams or so of THC, and they show that the patients had improved survival that were using cannabis.

[0:30:28]

Christopher:    Was it --

Stacy:    Oh, it was significant. It was significant. The problem is the study has only been reported in abstract form. We don't have a lot of details about the patient population, but people know about this. So at least, there's a little bit of data to say at least for GBMs, the one-to-one does seem to be effective, and they're using it for symptom control anyway.

Christopher:    So would it be possible for the pharmaceutical companies to pursue that as a drug? So if it's to something a molecule is found in nature, if it's not patentable, are the studies coming? Is what I'm asking, I suppose. 

Stacy:    I think that the studies are coming -- they will be coming in other countries because it's very difficult to do the studies in this country. If you want to do any cannabis research, you have to have a special license to do it, and also the cannabis has to come from a government place. From what I've heard, the quality is extremely poor. It's not what everybody else is using. 

Christopher:    So the government quality is poor? 

Stacy:    Yes. It comes from a special place, and that's all you can use. Now, they just approved Epidiolex, which is a CBD, high-CBD strain for the treatment of seizures in childhood epilepsy, these refractory childhood syndromes. So it's a drug that the doctor writes. It's a plant-based product. So I think it's going to crack, and I think we'll start seeing more studies. But actually to study, it would be great to study what people are using exactly. 

Christopher:    So I wondered if you had any ideas for that. So if each type of cancer is different, then and no doubt there's a great deal of variability between people too.

Stacy:    Yes. 

Christopher:    Can you think of a way that someone could figure out whether a specific compound was working for them at that time? 

Stacy:    Right. It's going to be very difficult. I mean, your traditional clinical trial is I have a cohort of 100 colon cancer patients, and we're going to treat them all with their standard of care plus or minus the cannabis products. But we know there's so much heterogeneity between colon cancer patients. Everyone doesn't have the same colon cancer, and it may not respond. So it's going to be tricky. Possibly we could move towards using xenograft models that they have been using.

Christopher:    You better explain that.

 Tracy:    Yeah. So it's possible that you can take a cancer cell and implant it on a mouse, and then you grow that tumor on the mouse, and you can test either chemotherapy sensitivity to see, does that work in that mouse or cannabis and what strain of cannabis is actually working on the mouse because that is that patient's tumor. So it's a surrogate or an avatar, is what they call it, of response. So that could be something that could be studied.

Christopher:    I’ve not heard about this before. You talked about it at breakfast this morning. How well described in the literature is this model?

Stacy:    It's all in research. There are some companies out there that will run chemo sensitivity testing, but it's not widespread. It's not widely used. 

Christopher:    Do you think you can do something in a mouse that you can't do in a test tube? 

Stacy:    Yeah, I think you probably can. But right now, I think, it's still a research setting and also it may be cost-prohibitive. So there's a lot of challenges with it, no doubt.

Christopher:    One of the other challenges that I was thinking about is when you've got patient that comes in and they say, "Oh, I'm using cannabis," then like you go, "What for? What strain? What dose?" You've got, literally, no idea what they’re actually taking, right? 

Stacy:    Well, I tell them to bring it in.  

Christopher:    The demo, could you like look at something in the back? 

Stacy:    Well, it will be labeled. I mean unless they're bringing in like a bud, and then I'm like, "I have no idea. I don’t even know what that is." But if they bring in sublingual drafts that they get from dispensary, then it'll have the dosing on there. Is it a one to one THC-CBD? Is it a six to one? At least I know, because some things you need a little THC like sleep, like appetite. You need a little bit of THC for those things. CBD is the big craze now. Everybody's taking CBD and it's like, what are you doing CBD for? CBD can be useful for anxiety. It can be high doses is good for seizures. It can be used for muscle spasm. It's actually approved in other countries for multiple sclerosis and pain from that type of thing. But cancer patients, I don't think CBD is that useful for them. They need a little THC.

[0:34:56]

Christopher:    Right. Yeah, I think what you said earlier which is there's probably lots of compounds in this plant that work together synergistically, and to isolate one could be a mistake. 

Stacy:    I think it is a mistake. The thing that I've just learned recently is that there are compounds in the plant called terpenes. So terpenes give the plant its characteristic smell and taste. Some of them are sedating, and some of them are activating. So an example, myrcene is a terpene that's very sedating. So if you want a product that's going to put you to sleep, the terpene is actually probably what's doing that, whereas a compound called pinene is more activating. So if you want to use something during the day that's not going to make you couch locked, then you choose something with a different terpene profile, and those terpene profiles are available at dispensaries. You can ask them for a certificate of analysis. 

Christopher:    Oh, wow. Even that's sophisticated. That's what you're just going to tell me, that the person in the dispensary just has so much experience. They're like, "Well, this is what it generally does to people." 

Stacy:    The budtenders, it depends on where you go and are they high at the time when you go into the shop, right? So I think if you can look at a certificate of analysis, you should be able to, from a good dispensary and a well-manufactured product, and it will tell you what's in it. It'll tell you all the different cannabinoids in it. They tell you it's tested for mold, metals, all of the --

Christopher:    It’s so impressive. It tells you how much money is involved when most supplement companies are not doing that. 

Stacy:    They have to do that now, though, because of state law. 

Christopher:    Oh, I see. 

Stacy:    It is very tightly regulated, and so you have that information available to you and you can look at it. So it's super cool. 

Christopher:    Yeah, it’s cool. Let's talk about some case studies. I know that you that some studies to talk about.

Stacy:    I do.

Christopher:    I’m very excited to hear about those. 

Stacy:    So let me pull those up. So yeah, I have a couple here, and this will kind of give you an idea of what I'm doing with people as well. It's always fun to go through cases. So I have a patient who had metastatic pancreatic cancer, and he was on some chemotherapy, pretty rough chemo. It’s a three-drug regimen. He had metastasis in his abdomen. You could see it on a CAT scan, spots in his abdomen. So when I saw him, he had an elevated hemoglobin A1c which is a marker of having too much sugar in your blood over a three-month period. 

Christopher:    And how much of that is induced by the drug, and how much do you think he was just diabetic before he even got into the system? 

Stacy:    Hard to know, hard to know. The drug itself shouldn't cause that, but some people are getting steroids when you're getting chemotherapy. So steroids will increase your sugar level and then possibly do that as well. Also, his vitamin D level is really low like below 20. 

Christopher:    Was there any history of not getting out in the sun? 

Stacy:    No, he was a pretty active guy. I mean, he lives up in the hills, and he's out on property and stuff. So he does get some sun, but it was quite low. He was getting some side effects from the chemotherapy, and the guy had a lot of stress. I mean, existential stress, like I'm going to die and I don't want to leave my family and really, really having a very hard time with it. I have a graph here. You can't see it, but when he was on chemotherapy, he has a marker in his blood called a CA 19-9 tumor marker, and it was going up. That's not good. If your tumor marker is rising when you're on chemo, that means you're not responding. 

    So as I saw him and we started working on with him, right away his CA 19-9 went from 2000s down to 500. It was on the rise. It wasn't a delayed reaction to chemotherapy because if the chemotherapy is working, it should have worked right away and it wasn't. It was months that he was on chemotherapy, and once we started working with him, his number shot way down. 

Christopher:    Can I share these slides in the show notes? 

Stacy:    Sure. Yeah. 

Christopher:    That would be nice. I really want people to see this graph. This is, I think, what we need to move towards is away from this idea that you need a randomized controlled trial done in another country with different people in different tumors in order to know that what you're doing is working and towards what I'm looking at right now where you could argue, okay, there's no counterfactual here. For all you know, maybe the cancer would have gone into regression anyway, but it seems a little bit unlikely. 

Stacy:    But based on my experience treating pancreatic cancer, it doesn't do this. 

Christopher:    Right. This doesn’t happen. 

Stacy:    This doesn't happen and it doesn't happen after months of being on the same chemotherapy.

Christopher:    So it seems vanishingly unlikely that this is a coincidence.

Stacy:    Yes, correct. So what did we do? So I put him on metformin. As you know, metformin has a lot of other properties. 

Christopher:    Yeah. Who knows how it works? I can’t --

Stacy:    I know it’s very complicated. It's like this weird black box of mechanisms.

Christopher:     I think what worries me about it, you probably heard, I listened to Jon Pardi, I think, on his HumanOS podcast recently. He had a researcher that's been looking specifically at the role of metformin and exercise. The takeaway that I came away with was it was probably a bad idea to take metformin if you're exercising. If you want to stay on the couch and do nothing, then take your metformin. But if you're exercising, it may block the -- so I should refer people to Jon Pardi to listen to that podcast. I'll link to it in the show notes. 

[0:39:58]

Stacy:    Metformin is a fascinating drug. In any case, I put him on that. He was eating some sugar and quite a lot of carbs, so I said let's cut back on that, obviously. Put him on a vitamin D. I put him on some turkey tail mushrooms, so the mushrooms, medicinal mushrooms, are immune enhancers and they're used a lot --

Christopher:    How do you figure out, though? The immune system is so complicated. How do you know which part you need to stimulate? 

Stacy:    Well, in general, the turkey tail mushrooms, they've been shown in studies in Asia to basically just improve natural killer cell function. It's the beta glucan component of the mushrooms.

Christopher:    I’ve read it. It is one of those things where you open the reset, just type beta glucan and there's like 60,000 of them. Okay, I'm just going to go ahead and close that one. 

Stacy:    I know, exactly. And a lot of it is from Asia because they use them extensively there. But there have been studies showing improved outcomes using this.

Christopher:    And do you have a favorite people? I love to talk about their mushroom coffee on every other podcast apart from this one, and I know that the quality again can be quite [0:41:00] [Indiscernible] at times. Do you have a favorite provider you like?

Stacy:    I use a company called Real Mushrooms. 

Christopher:    Yeah. I’ve used them too.

Stacy:    Yeah. Because they're using the actual fruiting body, which has -- and they published how much beta glucans are in their product as opposed to other companies that don't do that. So we did that. And then he was taking a couple supplements like curcumin on his off week because I don't like to do it right when they're getting chemotherapy. He was very interested in cannabis and the effects of cannabis on his tumor. So he was self-titrating up as well on his cannabis and doing his own thing with that. And we talked a lot about stress reduction.

Christopher:    Was it just the cancer that was his source of stress, or was there other thing too? 

Stacy:    Yes, because he's retired. He had a very stressful job, but he's retired now. So his main thing was just stress with dealing with death.

Christopher:    And do you think there's any problem with lots of meaning, like that really worries me in retired people, empty nesters, like my entire existence focused around childrearing. And now they've gone to college. What the hell am I here for?

Stacy:    So the book Radical Remission, that's a great book for people to read. It talks about commonalities of survivors. So what do people do that survive that weren't supposed to? Well, they ate clean food, they drank clean water, and they had meaning. They had something important to them. So that's a great book you can reference on the notes.  

Christopher:    Okay. There's a good point I've done recently, again from Simon, is this distinction between -- you hear people use the two terms almost interchangeably -- meaning and purpose. So purpose is, for me, it conjures up utility. What is the purpose of this screwdriver? Well, it's to tighten the screws, whereas lots of things could be meaningful. So for example, imagine a little old man in the basement of his house building model railways, and he finds that activity incredibly meaningful, that's going to hit the nail on that right there. 

Stacy:    That's the most important. 

Christopher:    Even though to me, that has no purpose, it doesn’t matter. 

Stacy:    But to him it does. 

Christopher:    Exactly. So it's very relative. 

Stacy:    So we talked a lot about ways that he could come to terms with this and be a little more at peace with it because he's a very smart guy and he understands that he's not going to be cured. I tried to tell him, it's not doing you any good to be worrying all the time about this. Try to make some meaning and purpose out of every single day, and don't get too far in the future. I like the power of now. I like the whole Eckhart Tolle way of thinking. He took that to heart. When I saw him back, he had radically changed his mindset. It was a dramatic turnaround. He talked about he befriended his tumors. He's like, "I'm not going to fight them anymore." He's like, "I want to work symbiotically with my tumors because if I die, they die." He's like, "I have a different relationship with them now. I don't feel as stressed. I'm getting out in nature. I'm enjoying every day." So he had a big turnaround. Now, I don't know what did it, but his numbers are still down. 

Christopher:    So he's still here today?

Stacy:    Yeah. 

Christopher:    And what's the average survival for that type of cancer? 

Stacy:    Twelve months. 

Christopher:    Wow. 

Stacy:    He's been out, he'll be out, I think it'll be -- well, he's definitely beyond that. I think he'll be coming up on two years, coming up this spring. And the tumor is the same. I mean, it's not growing at all. 

Christopher:    That's incredible.

Stacy:    Yeah. So he's had a great response. And then this is another great case. This is awesome. So this is a lady with triple negative breast cancer, meaning it doesn't express any. It has no estrogen on it, no progesterone and no HER2. So these are typically very aggressive. They're very mean tumors. She was on chemotherapy before surgery. So some people, when they come in, they've got a tumor that’s big or they've got lymph nodes involved, and we want to shrink it before surgery so the surgical outcome is better.

    So she's on chemo. She started fasting because she read something that fasting should be good for her.

Christopher:    Well, do you have an opinion on that? 

Stacy:    I think the jury's out on that, especially -- we don't know what types of tumors that that's going to be good for. Around the time of chemo, what is it doing? There are studies that are going on right now. They’re trying to determine that.

Christopher:    Does it worry you as an oncologist that this person might be cancer cachexia and not getting enough food to begin with and then…?

[0:45:10]

Stacy:    Sometimes that's a concern. So sometimes that is a concern, but for most people, it's not. Most people, they could stand to lose a few.

Christopher:    They could go a year without eating, it’d just fine. 

Stacy:    And if you do the fasting around the time of chemo and your chemo is every three weeks, you're only doing a little bit. They'll make it up when they're eating normally. But she did this on her own, and the thing with her is she had an elevated bilirubin in her blood, and it probably has Gilbert’s disease. So Gilbert’s is where -- 

Christopher:    Yeah, I've seen it all the time. 

Stacy:    Yep. So that's your UGT1A1 is not functioning properly, and so you have high bilirubin. 

Christopher:    So this is interesting because I've never thought there was really a deleterious negative health outcome.

Stacy:    There can be. Part of the problem with this mutation, it's not just a benign elevation of bilirubin. These people, they don't do well with alcohol, and they don't do well with Tylenol. That's what's going through this -- 

Christopher:    Do you measure direct and indirect bilirubin to figure out if that's what’s going on?

Stacy:    No, it's a SNP test that we send off to confirm it. So we sent it to Mayo Clinic. So we proved that she has Gilbert’s. Now, here's the deal. So people who have Gilbert’s, fasting makes it worse. 

Christopher:    Oh, wow. Interesting. 

Stacy:    So if you fast, your bilirubin goes up. So she shouldn't really be fasting, right? Now, the other thing that's important about this case is that her chemotherapy had to be reduced because of her bilirubin, because it goes through the liver. So her oncologist had to initially reduce her dose of her chemotherapy. So when I saw her, I said, "Hey, I know that broccoli sprouts extracts or broccoli sprouts can induce this enzyme. So I want you eating every day broccoli sprouts." I didn't really do much else like. Don't fast and start eating some broccoli sprouts because she's pretty healthy otherwise. So this is what happened to her. So her bilirubin went down from 1.7 to 0.3. 

Christopher:    Holy shit!

Stacy:    Her oncologist was able to then get her on full-dose chemotherapy. She had a good response, and then she went to surgery. Now, she knows she has Gilbert’s. I said, "You do not drink. Drinking is not good for you anyway because of breast cancer. Drinking is a risk factor for development of breast cancer. But don't drink and don't take Tylenol please and keep eating broccoli sprouts."

Christopher:    Oh, wow! So we have a product -- this is a good time for me to plug my own stuff like Real Mushroom. 

Stacy:    There you go. 

Christopher:    So we have a product called Hormetea.

Stacy:    I've tasted it.

Christopher:    It is pretty awful tasting, I have to say. 

Stacy:    I struggled a little but I --

Christopher:    Yeah. It's really good to put MCT or some sort of creamer in it to take the edge of the bitterness, it’s helpful. But the broccoli sprouts, they just ratchet and grow, like they just go moldy 50% of the time. It's such an ass to do it.

Stacy:    I know.

Christopher:    So you need something.

Stacy:    Yeah, and there's broccoli sprout extract powder too. You can buy it.

Christopher:    But you need to activate myrosinase, right? 

Stacy:    Yeah. They sell it at the stores where I live. So we've got it in all of the stores. So people can just buy it, the broccoli sprouts. And also, cruciferous vegetables.  Just eat a lot of cruciferous vegetables, and orange juice can also induce UGT1A1. But then you're getting sugar. You got to take metformin. But in any case, she didn't even know any of this. No one even had paid attention to her bilirubin ever. She's 50.

Christopher:    I don’t. 1.7 is up there, but I see elevated all the time. Like, just the assumption is you Gilbert and it's benign. 

Stacy:    So another case, this is a typical person I see, absolutely typical. So a lot of breast cancer, but this lady was 40. She's overweight. She had an ER-positive tumor, HER2 negative, so a better actor and this is a very common profile. She had chemo and radiation. She had a standard American diet, really horrible sleep. She had a lot of stress. Kids running around. That's the problem with a lot of these patients. They're 40, they've got little kids, they've got elderly parents, they're busy, they're working, and then they get cancer. So it's like stress central, right? She was 166 pounds, a little bit overweight. Her A1c was 6.5. 

Christopher:    So she's diabetic.

Stacy:    No one ever told her, never checked it, didn't know, no clue. Her vitamin D was low. Her CoQ10 was low, which I see a lot actually after chemotherapy. I think chemotherapy depletes CoQ10. I see it again and again. 

Christopher:    Okay. You just told me what you did with these other patients, but you would consider supplementing with CoQ10?

[0:49:55]

Stacy:    Yes. When they're done with their chemo, yes. So with her, again worked on diet, diabetic diet, low carb, a lot of plants but good quality meats if she wanted to, fish, tofu. I talked about intermittent fasting with her, so restricting her feeding window. Got her to exercise. She was not exercising, and added in some resistance work, put her on some melatonin and meditation for sleep, and her stress reduction was a work in progress. So follow up, in two months, her A1c was down to 5.6.

Christopher:    So you basically fixed the diabetes. 

Stacy:    Yep, fixed her diabetes. She was so motivated. Now, her weight was not coming down that much, but she's going the right direction. She lost a couple pounds. She's sleeping, he's exercising, and she's really, really happy. This was what struck me about this case is she was beaming when I walked in the room. Her numbers are great. She's got a new attitude. This never would have happened before. So I love seeing this. 

    I just have two more real quick. This is a quick nice one. So this is a lady who had chemo, 75-year-old lady, three years ago, so for breast cancer. She had neuropathy, tingling and numbness from her chemotherapy which is super common problem. A lot of people get in their fingers and in their toes, and it can be debilitating. 

Christopher:    Right. It feels like you’re wearing gloves and socks, right?

Stacy:    They can feel like pins and needles. It can be painful, or it can just be numb and then you can't feel your feet. 

Christopher:    Right. You see people walking like that sometimes. They're like the diabetic --

Stacy:    Exactly. They can't feel, so their proprioception is off. So in any case, it was really bad. Over the last few months, it was actually getting worse which is kind of weird. Her chemo was three years ago, you think it would be getting better, but it was actually getting worse. So I'm like, okay, what's going on? She was taking a B complex and a multivitamin on her own, and someone put her on Neurontin, gabapentin. 

Christopher:    You have to tell us what that is. I've heard about it.

Stacy:    So gabapentin is used for diabetic neuropathy. So it modulates -- it doesn't cure or help the neuropathy, but it's kind of like a pain modulator. It's actually like an anti-seizure medicine. That's the class that it's in. It has a lot of side effects. So people get dizzy. They don't feel well. She was really dizzy, did not like it, and it wasn't helping her. 

    So we did some blood work, and her B6 level was really, really high. She was supplementing. She just thought, she read somewhere that would be important. Well, actually, it causes neuropathy. So high B6 can cause neuropathy. But her glucose and A1c were fine, so we ruled out diabetes in her. I told her stop your vitamin. Stop your B6. Go get some topical cannabis, cream. Put it on your feet at night. There are receptors in the peripheral nerve endings. There are cannabinoid receptors, and also CBD interacts with a receptor called TRPV. It works like capsaicin. So it can be useful for peripheral neuropathy, and it doesn't get absorbed systemically. Because a lot of people, they don't want to take cannabis, but they'll use a cream. So I saw her back in two months and her neuropathy was 90% better, and she came off Neurontin. 

Christopher:    That's great. Do you worry about that, like the isolated B vitamins? They all work synergistically and maybe a food-first approach.

Stacy:    And too much is not good. What's up with vitamins when you look at how much they're putting in it? It's like 10,000% of, you know. 

Christopher:    Yeah. Part of that is because the benchmark is just completely bonkers, right? The adequate nutritional intake is just completely nuts. I still think that the food -- and don't get me wrong. I take a multivitamin. My kids take multivitamins. But just isolating single B vitamins, unless it's like clearly indicated. 

Stacy:    Unless you need it. If you have a problem with your homocysteine or whatever or your methylmalonic acid. I use methylmalonic acid to check where I'm going with B vitamins. 

Christopher:    Right. And is that in blood or in urine? 

Stacy:    Blood. 

Christopher:    Okay. So you got to know what you're doing with B --

Stacy:    Right. And the other caveat is cancer patients can often just run a high B12 level anyway. I don't know what the mechanism for that is, but --

Christopher:    Oh, I'd like you to shed some light here. So what do you measure? You're measuring just serum B12?

 Stacy:    Yeah, just serum B12.

Christopher:    Yes, it's a useless biomarker because in the gut, there's certain microbes producers bacterial coronoids that cross reacts with the assay. So you need to either measure methylmalonic acid, which is what you just said, or I think there's something called hydroxocobalamin which is a test that's commonly run in the UK, but it's kind of hard to get over here. But you can measure methylmalonic acid in blood or in urine, and that is indicative of a B12 deficiency.

Stacy:    Right. That’s what I use.

Christopher:    Yes, it's serum B12. It's really quite useless. 

Stacy:    I just see it on panels. 

Christopher:    Yeah, people run it and --

Stacy:    And then what happens, they come in and their B12 will be like 3000.

[0:55:00]

Christopher:    Yeah, and they're like, "I don't even take anything with B12."

Stacy:    But there’s an association with cancer. 

Christopher:    Okay. So the connection is probably the gut. 

Stacy:    Right, exactly. So this is the last one. I saved the best one for last. This one is awesome. So 59-year-old lady with recurrent uterine cancer. She had metastasis in her abdomen, and you can measure it on a CAT scan and biopsy proven, by the way. So someone put a needle in it. It was low grade, and it was estrogen positive, meaning it's being driven by estrogen. This was a thin lady, kind of not great diet, kind of stressed. She had a tumor marker in her blood called CA 125 and it was elevated at 44. So not super high, but it was elevated. She refused all treatments. 

    So I do get these people that come in and they're like, "I will not do chemo, and I don't want to take any anti-hormones. I'm just opposed to everything. I want to do everything naturally." I kind of have a hard time with that sometimes. I try to tell people, well, I don't think that that's the right thing to do. Why don't we try both? Why don't we try both approaches?

Christopher:    What do they say to you? That's a kind of very interesting -- I mean, is it synthetic curcumin? Let's say synthetic is like a [0:56:12] [Indiscernible] thing, like it's really a drug but --

Stacy:    It’s a drug, but they don't think of it that way. People think, they have this thing about chemotherapy or tamoxifen, like, these are pharma. This is big pharma, and I think it's poison. I hear that word every day -- poison. It's like, well, I mean, it has a place though. If you have bad cancer and you need to get it under control, you kind of need to do some chemotherapy.

Christopher:    Just trying to get people away from this all or nothing thinking. 

Stacy:    Exactly. 

Christopher:    Either it’s like a poison or it’s a cure, right?

Stacy:    Right. Why not try both? Let's do what we're doing, but then let's do some standard therapy. 

Christopher:    How often are you successful in talking to these people off the ledge? 

Stacy:    Well, the people who are really, really anti-treatment, there's nothing you're going to say that's going to change their mind. 

Christopher:    I mean, surely sometimes it must be justified, like you have a particular type of cancer where we know the prognosis is terrible. 

Stacy:    Oh, that's different. Yeah, that’s different. 

Christopher:    I don't want to spend the last 12 months of my life spending a ton of money on something that makes me feel miserable.

Stacy:    Correct and I totally get that. A lot of these people, especially when they're just first diagnosed, there's a couple things you could do that are not that bad and it could extend your life by, you know, it could be years. So in any case, I try to reason with them and work with them, but again some people, like this lady, she just said, "No, I'm not going to do that."

    So her lab showed that she was low in D. Her methylmalonic acid was high. Her CoQ10 was low. So we replaced all of those. I put her on for curcumin 1500 a day, put her on fish oil, green tea, put her on a good diet, got her exercising, and again work with her on stress reduction. So on follow-up, three months later, her tumors were smaller, and this was on a CAT scan. So her tumors went from 3.3 centimeters to 2.5. This is what you would see with chemotherapy. She's not doing chemo. 

Christopher:    That's amazing.

Stacy:    And her CA 125 tumor marker, which was 44, and now it's down to three. 

Christopher:    That's incredible. 

Stacy:    And all of her other markers are better now. So she's absolutely ecstatic and going back to her oncologist saying, "And I told you so." I'm just thinking in my chair going, "I didn't tell her to do this." But it's like, I'm trying to work with people with where they're at. But that's pretty impressive.

Christopher:    Right. That is very impressive. Congratulations. My question is, is it possible to tease apart like what are the things that having the greatest impacts? Could a health coach have done this? So no supplements, no CoQ10, no curcumin, none of that fancy stuff. Just the basics, the pillars of health -- the sleep, the exercise, the eating, the drinking, the stress management. Could they still -- 

Stacy:    I don’t know. 

Christopher:    You just don’t know, do you?

Stacy:    I don't know. I mean, when someone has cancer, you don't always have time to sort of --

Christopher:    [0:59:01] [Indiscernible], right?

Stacy:    Exactly. And like the things that we did, they’re not that hard, right? Green tea and curcumin, they both have anti-cancer properties. They both do. They’re antioxidants, and they also block multiple pathways that cancer cells used to proliferate. So again, I don't know exactly what we did that worked. It probably was a combination of everything, in her case. But in another case, they may not get the same results. So it's challenging. 

Christopher:    That's amazing, though. So what happens now for everyone else? I'd be pissed if found out there's this better thing. I walk into Sutter, I don’t even know that down the corridor there, there's this…

Stacy:    Yeah, so we'll be expanding our clinic just so that we can see more patients. So I'm going to be hiring some nurse practitioners to help me. What I like to do is start doing some more education for the other physicians because they can do some of this stuff too, and they can incorporate some of these into their practice. Simple things. There are simple things that any doctor can do. So that's my plan.

[1:00:07]

Christopher:    If they weren’t so busy typing stuff up up into this electronic health record thing.

Stacy:    Exactly. But if they could just have a few labs that they could check and just start nudging people toward a healthier diet and lifestyle, I think it will go a long way. The nurses can play a role in that too, right? So educating the nurses.

Christopher:    Right. But do you think that there's kind of this paternalistic, and I don't mean to use that in the masculine sense of the term, but there's this paternalistic thing that some people respond to really well. Well, my oncologist told me that this is the best diet for my particular type of cancer. Do you know what I mean? It’s like coming down from above. This person knows more than me. Will they still respond in that same way from a nurse practitioner or a health coach or someone other than you? 

Stacy:    I think if they are of the mindset that they're actually seeking out this type of care which they do. I mean, they're looking for it now and if they see my flyers or they see the the service that we're providing, I think they will be responsive to it. 

Christopher:    I mean, that's another thing. That's another confounding variable right there. It's when you've got someone that's this motivated because it's hard. I'm not saying that chemotherapy is easy. It's just that all of the things that you've talked about, diet and exercise and not drinking so much and stress, these are all the really hard -- we know that behavior change is super hard.

Stacy:    It’s very hard. 

Christopher:    So is it just that you're selecting a group of people here, the most motivated, they're putting their hand up and saying, "You know what? I really need help with everything"? Of course, they're going to get better results because anytime anyone puts their hand up like that, they're going to get better results. 

Stacy:    Yes. And there are people out there that aren't going to change, and those people, we don't see them. These people have to be willing to work with us and make changes in their life, but you're catching them at a time where they'll do it. 

Christopher:    I think we've done a really good job of covering all the bases, but is there anything else that I should have asked you about that would prevent me from being your patient in the first place? That's what everyone listening to podcast really wants. Stacy sounds great, right? I want to see her.

Stacy:    Well, for now, I'm just seeing people with cancer, so you probably don't want to see me. That’s the thing. I'm only seeing people who have a diagnosis.

Christopher:    But what I’m saying, in your opinion, what are the pillars of health that people need to think about if they don't want to get cancer? 

Stacy:    Oh, in terms of prevention, in terms of prevention. 

Christopher:    Exactly.

Stacy:    So definitely diet. I think diet is a way up there. Get off processed foods. Stop eating junk food. Stop eating sugary foods and treats. Your standard American diet is horrible. Water. There was just a study coming out showing that there's so many contaminants in our water and that that may be a contributor for cancer. So get a good water filter.

Christopher:    It is such a low-risk intervention. I don't know about that study, but I'm not going roll the dice on that one. 

Stacy:    Just filter, easy things. Get moving, exercise. Exercise as much as you can for the most part. Keep the stress down, for sure. As I was saying, if you ask my patients, that's their number one reason that they got cancer. We know stress, all the bad effects of stress. So stress raises your cortisol levels and your insulin levels go -- I mean, it's just like this cascade of bad hormones that set this. I don't think it necessarily causes the cancer, but it kind of like gives it a nudge. 

Christopher:    But when you think about it, like Robert Sapolsky has been very good on this topic, actually, and I think this is in Why Zebras Don't Get Ulcers, right? What you're basically doing each time you get stressed out is you're liquidating your assets and you're putting your money into defense, the expensive education. So it's like, you can't -- yeah, basically, you're liquidating your assets. 

Stacy:    Exactly. 

Christopher:    You think about the immune system, that's a long-term building project. And if the immune system plays a critical role, I mean, we're all cancering. It's just the system takes care of it. 

Stacy:    Exactly. 

Christopher:    But if you're stressed out all day long, then maybe the immune system isn't taking care of it.. 

Stacy:    So it's like being on steroids. What steroids do to you? They suppress the immune system. 

Christopher:    That’s what they are, the glucocorticoids that --

Stacy:    That's right. That's exactly right. And sleep. People are not sleeping well. So sleep is hugely important in restoring ourselves, just restoring our body. So I think just the basics, like if you can get people to do the basic things, I don't think there's anything magic. There's no magic supplement. You have to do the hard work.

Christopher:    Right. No silver bullets. What would you say to -- imagine I was a doctor listening to this, and I was trapped inside of a system that I know is not working, the system that you were trapped in. How long ago was it now? It's about five minutes ago, isn’t it? It's not that long. 

Stacy:    Yeah. Right. 

Christopher:    So how do I bust out the system? This is not what I signed up for, right? The reason I went to medical school is because I wanted to help people improve their health and recover from disease. Now, I'm in the system where I don't feel like what I'm doing is giving me adequate scope of practice. Maybe I'd love to talk to people about their diet and sleep and all the rest of it, but the only tool I have in my box is this prescription pad. Now, how do I bust out of that? 

[1:05:02]

Stacy:    I think there's more and more opportunities for that. I think, if you're interested in training in integrative medicine or functional medicine, there's a lot you can do. You can do it all almost online right now and it's great.

Christopher:    It's the IFM stuff that you did. 

Stacy:    I went through IFM. Many of our integrative doctors that work at Sutter, they've gone through Andrew Weil's training program out of University of Arizona. So many of them have done that. Some have done A4M. So it's kind of like there's a hodgepodge of different training that you can go through.

Christopher:    And it probably doesn't matter that much which one you pick. 

Stacy:    I don't think so. I don't think so, especially if you're just in general medicine, I don't think it matters. I think for cancer, it was difficult for me because there wasn't anything super specific for cancer. But in any case, I think you can make it work in a health system. I'm making it work by I bill my time, so when I see patients, I'm billing by my time. I'm RVU based, meaning I get paid per unit of what I'm seeing. So the more people I see, I don't really like the model, but it is what it is. 

Christopher:    When that actively works against you, when you're spending more time on it --

Stacy:    Well, I am but I coded appropriately so that I get paid -- I do fine with what I'm doing. And then my follow-up visits are 30 minutes and if I have to schedule people more frequently, I will.

Christopher:    So we should make it clear that you're working inside of the --

Stacy:    In a health system.

Christopher:    With the accepted insurance. We’re not talking about --

Stacy:    With insurance. This is all insurance based. 

Christopher:    Like that doesn't exist, right? We get people come to us all the time saying, "Oh, who can I see that does what you do but takes insurance?" And my answer to that is like, you don't understand. As soon as you take insurance, you're trapped inside of a system that doesn't work. That doesn't exist. 

Stacy:    You still are going to have to deal with your charting. You're still going to have to find ways to deal with the stress of whatever system you're on, Epic or whatever charting system that you use because you still have to bill, right?

Christopher:    Right. 

Stacy:    But my feeling is at least you're doing work that is meaningful to you if you're seeing positive changes, and I'm seeing other physicians around me that are kind of waking up to this and saying, "I'm seeing a different way of practicing." The Integrative Medicine Department, they're the same way. They are all insurance based. They bill by time, and they do group visits. So that's another mechanism of increasing your revenue is you can see a group of patients and bill each person on an individual level for a group visit. Some of them will do telemedicine. So all of these things are possible within a health system. It's just what system are you in? Are they rigid? Are they going to be flexible with you? And then many practitioners are just going out on their own, and they're just opening --

Christopher:    That's a really tough thing. I think all doctors know that they could do that. If they were sufficiently entrepreneurial, then they could start their own private practice, but that's pretty scary. 

Stacy:    It is very scary, I think. That's why a lot of people feel trapped. I don't have the ability to do that, but I've made it work so far, and it's been great. The feedback I'm getting is just phenomenal. I couldn't say any more good things about it.

Christopher:    That's amazing. The excitement in your voice is palpable. I worry about that you might burn out again because all of these consultations that you're giving, they're so emotionally draining. Tell me what it's like after you’ve spent five hours talking to patients about their sleep.

Stacy:    Yeah. Well, I started out seeing four new a day. Okay, so four new a day because I hadn't built up the follow-ups yet and four new a day was a lot. I was drained. Again, like I said, before I could do that and keep it in check because I was just talking about their cancer and their chemo and this is what we're going to do. Now, I'm talking to them about they have emotional scars and they can't sleep. I'm listening to them almost like a therapist, and I feel bad. So I have this give and take with them that is very different than what I was doing before. So yeah, it can be draining. So as I started building up more follow-up patients, I'm like, I got to go to three a day because I'm just too drained. Now, as I've got more follow-ups, I'm going to two, so I'm going to see two new a day. Even two new a day --

Christopher:    That's what I'm thinking here in the back of my mind is like, how do we scale Stacy?

Stacy:    Yeah, I know. I know.

Christopher:    We know that you probably can't just hand these people off to health coaches that perhaps could do the lion's share of the hard work because they're going to say, "Just the doctor, please. Thanks very much."

Stacy:    Yeah, yeah, yeah. But if I can teach a crew to help me with managing this, and also if I can get some basic education out to the other doctors, that's what I view as part of my role, then I can scale up a little bit. Even if I talk to them about simple things like, "Hey, if your patient’s on chemotherapy and they're doing chemo radiation for pelvic cancer, put them on this probiotic because they'll get less diarrhea. And here's the paper. Here's the reference." So I need to start working on that in my spare time. That's how I can scale up. Also, another way, I think, of scaling up is eventually maybe teaching. So I love to teach for IFM or another type of place where I can do. I love giving lectures. I think it's really fun. And then teaching other practitioners out there, just these nuances about cancer. 

[1:10:15]

Christopher:    And is there any possibility of doing group sessions for patients? That's another way you could scale, right? 

Stacy:    Yes, we can do group sessions. 

Christopher:    That would be awesome. And then maybe something special about that on its own. It's like they get connected --

Stacy:     The camaraderie. Yep, and people are already doing that.

Christopher:    That's incredible. Well, you’re doing amazing work, Stacy. 

Stacy:    It's pretty awesome.

Christopher:    Is there anything else I should have asked you about? Oh, I know I should have asked you. So if I'm listening to this and I would like to see you as a cancer patient at Sutter, is that possible? What's the waitlist?

Stacy:    So we, obviously, need a referral. I think I'm booked out in the Roseville location a couple months. 

Christopher:    That's not too bad.

Stacy:    It's not that bad. I think I'm in the December for a new patient in Roseville and in Sacramento a little sooner. It's still possible, but the referrals are just piling in, so it's getting busier and busier. That's why I will be hiring more people. But yes, we take most insurances. There may be a few that we don't, but we would just get a referral from the physician. 

Christopher:    Okay. Is there anywhere else that you would send people? So for example, if I can't get into your practice, if it's physically not possible for me to get to Roseville in California, is there anyone else like you that's doing the similar sort of work, or is there like a network of providers that people could search in?

Stacy:    So there aren't that many doing cancer-specific work, but there's certainly a lot of integrative practitioners out there that work with cancer patients. So if you look in Society for Integrative Oncology, they have a listing of physicians. And also IFM, they have a list of practitioners and you can search by state. So you'll get similar concepts from a practitioner who studied in either integrative or functional medicine. You're going to get very similar things. 

Christopher:    We were talking about that at breakfast that I went to Sutter to see that gastroenterologist. I come to see you and we've not even mentioned the word cancer because as far as I knew, I hadn't had that diagnosis. It was something completely different. It was IBS and I followed your recommendations and maybe taking a couple of supplements that you recommended. I would have gotten just the same results as the ones that I did even though ostensibly they would like --

Stacy:    Right, exactly. 

Christopher:    Yeah. That's super interesting. Was there anything else I should have asked you? Is there some way that people can find you online?

Stacy:    I don't quite yet have a website. We’ll be developing one for our center. We haven’t done that yet. 

Christopher:    Well, it's not really necessary if you're already booked out.

Stacy:    I know. We really haven't advertised either just because I'm worried. I have a couple of lectures coming up to primary care physicians, talking about what I'm doing, and I'm afraid I'm going to open the floodgates because the PCPs don't even really know about me yet.  

Christopher:    Have you got speaking engagements coming up? 

Stacy:    I do. I have a couple for primary care physicians, one in Sacramento mid-October, and I have another in Modesto. I'll be doing a cannabis lecture in Nevada City in mid-November. I can give you a list of all the different -- 

Christopher:    Yeah, we'll link to that. 

Stacy:    That'd be great. People can sign up for those lectures if they're interested. 

Christopher:    Elaine does a fantastic job. She spends up to five hours making the show notes for each episode which is something I'm really grateful for. Elaine is very, very good at tracking down the scientific references for everything that you just mentioned. So you can find us over at nourishbalancethrive.com/podcast, and I'll link to everything that Stacy mentioned during this interview. Well, I think it's an incredible work, and I'm so excited for you. 

Stacy:    Thank you. I wouldn't be here without you. You guys got me on this path.

Christopher:    Well, I like to think that there's no mastermind. I feel like it was just something that you were ready to find. If not me, then it just would have been someone else.

Stacy:    Eventually. But all the pieces just seem to fit. So great. 

Christopher:    Well, thank you, Stacy. I appreciate you. 

Stacy:    Thank you.

[1:13:53]    End of Audio 

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