Episode 87: How Can Personalized Medicine Transform Cancer Treatment for Patients?

Foreign.

Dr. Rob Whitfield, the board certified plastic surgeon specializing in explant surgery.

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All right everybody, I have a very special guest today. I heard Dr. Rayan Goshen speak at a meeting I attend. Many of you know I'm a member of the Da Vinci 50, which is a long longevity group, but they're constantly looking for great speakers and I don't know if you could find a better one than Dr. Goshen. He was very compelling when he made his lecture to us. And so everybody knows I've done a lot of oncologic surgery. I've worked on multidisciplinary cancer teams. But many of the things that I faced were reconstructive challenges and many of the things the medical oncologist and or radiation oncologists I would take care of were far outside my purview. So I'm going to let Dr. Goshen talk about the problems with chemotherapy not working properly or cellular things that, that lead to resistance and mutations and all the things that, you know, make it very difficult for the medical oncology groups to treat patients with cancer.

Thank you, Rob. First of all, thank you very much for having me in your, in your podcast. It's a pleasure. It's an honor. If you don't mind, I'll take it maybe a level higher than that. And let's talk a little bit about cancer. I would approach today cancer as the most common, rare disease. It's actually an end of one disease. Why do I say so? Because we have all the diagnostic technologies available today for us at our fingertips to sequence, to fully sequence the whole exome, DNA, RNA proteins. So we get so many data points just per the tumor put on top of that, if we look into the failure of the defense mechanisms, and I'm sure Rob talks to you a lot about that within the discussion about longevity. So the failure of the immune system, the failure of many metabolic pathways add Those data points to the equation. And on top of all of that, put patient incentives and patient limitations, then cancer becomes an end of one disease. And that's why you keep hearing.

Can we say something about that? So when my listeners hear I talk about their own personal genetic material quite a bit and limitations in immunity. So we use a lot of. I approach the problem of chronic disease from a level of inflammation, and we'll say inflammation at the cellular level, that it causes inhibition in certain pathways, things like vitamin D synthesis, active uptake, transports, things like methylation, pathways for DNA repair, things like glutathione utilization or liver for detoxification, and certainly antioxidant pathways that lead to mitochondrial dysfunction, which for my listeners have heard me talk about this a lot, that leads to a lot of fatigue. And so our patients, we talk a great deal about how our personal genetic material, we only have a set of one gen, that's the playbook. And then how environmental stressors and other things we do, how we eat, how we drink, how we sleep, the activities we participate in, lead to the expression of those genes. But what you're saying in addition to that is these cancers have their own genetic profile, Correct? Okay.

When I was referring to the whole exome sequencing, I was talking about the.

Cancer exositosis, two different profiles. Yes, absolutely correct.

So if we add all of this together, cancer becomes an N of one disease. And that's why you keep hearing about precision medicine actually embarking first on oncology. And. But this is a big challenge. It's a big challenge for any healthcare system. And I'm not, I'm not going to talk about any specific healthcare system, but if you just in general, in general, if you come to think about healthcare systems, they have different stakeholders in the system, Right? They have the patient as hopefully the most important stakeholder in the system, unfortunately, the weakest one. They have the insurer, the payer there, they have the regulator, they have the pharma companies, they have biotech companies, they have the providers over there. And unfortunately, as you all have probably experienced in your lifetime, they have misaligned incentives. Not because anybody is a bad person, because oncologists are bad doctors. I tend to think that, generally speaking, oncologists are good doctors because they came for a good reason to manage cancer patients, but they have other incentives that are not necessarily aligned with the patient's incentives. And the patient who consumes the services.

For the life and the, the big food industry is definitely part of that as well. That's another huge stakeholder in Our country is big food. So I talk a great deal about the quality of the air you breathe, the quality of the fluid you put in your body, and the quality of the food you eat. And you know as well as I do, people who are unhealthy or people who have what's called natural killer cell suppression are certainly more susceptible to cancer. And so I talked to this, I speak to this subject, I talked to my clients, and I say now, the pharmaceutical industry created a drug, a GL1P agonist. And so this class of drugs, if they knew what it was doing before they submitted their final approval to bring it to market, do you think they would have brought it to market? My short answer is no, they wouldn't have. Because this drug changes behavior. And when you change behavior, you have the most powerful tool you've ever had. Because every doctor knows the hardest thing to change is a behavior, Period, End of story, full stop. If I could control people's behavior, I would have absolutely no issues in recovery because people wouldn't hurt themselves. They wouldn't put bad things in their body. They would really carefully control what goes into the most important, highest performing thing they have, which is their body, period. And you watch. And I was going to ask you, do you think the incidence of cancer will go down because obesity is going to go down, diabetes is going to go down, all these things that are going to be modified by behavior modification because GL1P agonists turn off binge behavior. Binge behavior to me, makes you eat later, affects your digestion, increases your inflammation, you don't sleep well, your hormones don't get secreted properly, you can't recover. It becomes a chronic cycle. Then I think affects in case suppression in my patients for sure, along with their other problems that leads to more problems with cancer.

I cannot agree with you more on that, but I would take it again in a more general aspect. There is no doubt, I think, that we are seeing changes in the epidemic of cancer as we go today. One thing that becomes very clear, that for specific cancer types, colorectal cancer for definitely, we see more and more young patients. We see patients absolutely in the 40s, in the late 30s, which was very uncommon for us. Post pandemic, we see changes. So there are, if I take it in a very broad spectrum, what you just mentioned about the GL1P, I would say that it takes usually decades before we acknowledge what have we done with the introduction of a new modality of treatment to this world. So, yes, I totally agree with you on that. Notion and definitely see changes today. The last couple of years, we see young patients. As you know, colonoscopy is now being already recommended at the age of 45, while we were pitching to start that at the age of 50. And we have had in our company not one and not two and not three patients in the late 30s with colorectal cancer without any family history. So it's not the genes that you talked about when, it's the genes that cause it during their own life course. So, yes, I do agree with you.

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But.

So we'll take an instance like that where you have somebody, we'll say, like my mother, she has a recurrence. It's going to be resistance chemotherapy. And then you get that call. And Rand, how does your team, you know, then kind of react? Because I think that would be your. Your niche.

Correct? Yeah. So we developed a totally new approach, and that hopefully is going to disrupt medicine and the provision of healthcare in general. But we're starting that with oncology. With cancer, the whole concept changes because we really want to put the patient at the center. In order to put the patient in the center, we need to be fully aligned with the patient incentives, unlike what I just shared with you. So, for that matter, we provide a service which is called patient personalized oncology Advocacy poa. What does that mean? It means that we take those experts, the oncologists, and the oncology PAs, we change the names to become a lead oncology advocate and an oncology advocate, and we totally change their role. The role from now on is not to treat the patient, but to help the patient. At any point that a decision needs to be made by advocating for them. That means we are staying away from the provision of care. And we behave, for the lack of other analogy, we behave like a family member. We will talk to you about everything. But that's not just enough, Right? But we have developed, aside from the methodology of the advocacy work that I've been doing for more than 12 years, we have developed a whole technology that supports it today, and we are Riding on a great wave of AI which helps us do it. We have developed an amazing technology about patient data management. AI already incorporated into that. So say that the patient comes to us like your mother, already being treated, first line and failing on that. And imagine, imagine that she would have come to just get a second opinion. She would come with two plastic bags with 3,000 pieces of paper over there and say to the doctor, here it is everything that you want in the earth. Nobody can capture that. Our technology, our platform does. It automatically collects, identifies what is this very single document and it extracts the data out of that and it presents it to our team, to our advocacy team in a sophisticated manner there for a second.

So I get this a lot. I have people who've been to the Mayo Clinic, the Cleveland Clinic, the biggest clinics in the world, looking at their inflammation. They show up with reams of paper. Most of that, you know, laboratories, standard laboratory analysis. So your AI, we'll say reader or system takes all of that information, it aggregates it, puts it all together and synthesizes it and summarizes it for your team.

Correct.

Okay.

And present in a very nice viewer that gives everything, provides the advocate with a timeline and everything is being shown. And you can filter what you want to see. Do you want to filter in or out anything you want to filter out patient encounters, filter those out and stay with lab tests and imaging tests. And with a click of a button, one click, you'll get the original document, but you'll see everything presented over a graph, all the imaging studies you will see. But let's stop the technology. I mean, I think what will be of interest to your listeners is that this poor, this specialized oncology advocacy service goes for one year. During this year, as I said, you have a team which is being led by a very senior US based or Canadian oncologist and a PA that constitute this. The two of them constitute the core team of the advocacy team and they will take you through the first very heavy lifting, which typically goes for three to four months. We call it the planning and intervention phase. During that phase, we will a upload all data that have been accumulated, regardless of their original format. So even if you go to Sloan Catering or biochemical cancer patients may have their information dispersed all over the country.

Right?

We are ignorant of that. We don't care about that. We will collect it from everywhere. So we will collect all the data, we will present it on our platform, and then we will identify, first of all, if there are any diagnostic gaps. Just to review the diagnostic, the diagnostic Work that has been done and maybe more importantly, identify other diagnostic tests that are not yet part of the guidelines. And we can talk in length about guidelines and the limitation of guidelines of the NCCN guidelines. Not God forbid to blame them on anything. But as the former CEO of Cleveland Clinic said, Every 120 days there is a significant innovation in healthcare. It will typically take 12 years to be adopted by the system. What happens if you get cancer in between this 120 and 12 years? Can you get access to these CLIA approved labs that do? And I'm sure that the labs that you are using are CLIA approved, but they are not part of the regular tests that will be offered to patients in great medical centers. So we will identify those and we will think ahead of time about therapeutic intervention that may come up later on down the road like cancer vaccines. And then you will be looking for a flash frozen specimen. But if you do not flash freeze it in the very first surgery, then you don't have it anymore. And if you want it to be kept in minus 80 centigrades, then you have to care for that earlier and keep it. So many things like that. We will collect all this data. We will do the gap analysis, and once we do the gap analysis, if we identify things that may be valuable for the patient to consider, we will offer that and we'll tell the patient, you will have to decide about it. We are not telling you that you need to do that. You go and take it with your either primary care physician or with your oncologist, or you decide by yourself. And if you do decide to do that, it's on us to help you execute it. So we will do those, we will retrieve the results of that and then we go to the planning of the treatment. We will review with the patient everything that has been offered to her or to him by their providers. But let's admit it, cancer patients get to see an oncologist every two to three months at maximum for 15 minutes. Not because the doctor, the oncologist do not want to sit with them for a longer time. God forbid they would like to, but they are overwhelmed by work. Okay? Oncologists are the most burned out physicians in the system, so they cannot afford one. And they talk to the patient in using nomenclature that they don't understand. We will take the time, we will take the time to make sure that you fully understand that the patient fully understands in a jargon free way everything that the doctors have been offering them. Moreover, and most importantly, we will do for them the research, what is available for them that has not been discussed by them, by their current care providers, and why this has not been discussed with them for a couple of reasons. And we go back to the misaligned incentives. The providers and the insurers are sticking to the guidelines because that creates a very common language for everybody to speak with each other in a world of misaligned incentives. Right. What is good for the provider, for the insurer or for the payer is totally different from what is good for the patient for the. For the payer. It's very simple. It's financial terms. I mean, they need to collect more money than they spend, otherwise they lose their business model for the provider. For a doctor like me operating on a patient, I have couple of thoughts that I have to take to mind. I have watch for liability issues, watch my back. That's very important. I have. So sticking to the guidelines keeps me at a very safe place. I have to manage my time and this is also my job and I have to make my income. And yes, I do want to do my best to my patients, but I have conflicting. So we will take it out of this range because we are not providing care. We are professional consultants using professional technology to curate data out there. And when we do that, we will be able to offer cancer patients what is there out there which is not part of the guidelines. It may be clinical trials or it may be even options that are available somewhere on either compassionate treatment or. Or on a commercial basis. There are new treatments that are available outside. For example, outside of the geographic boundaries of the US either south of the border or either in Europe. Because in Europe, the regulation is much more flexible about what we call N of 1 clinical trials. So within the first three to four months, we will do all of that heavy lifting and make sure that. That by the end of this time period, by the end of the planning intervention, our client is already at a point that she or he already made their decision what they want to do, and we have secured that they were able to execute upon that. The rest of period is the surveillance.

I mean, I think, you know, what Dr. Goshen has said is he has put forth a plan that currently, in my, you know, over 20 years of doing this, I've never seen, because, you know, from a multidisciplinary perspective, all we ever wanted to do is have a navigator help the patient do what you just said. But now you're taking the most sophisticated type of navigation in individualizing it and almost like handholding them through the process. So for everybody listening, you know, even at, at my age when my mother was diagnosed and had this treatment plan set forth according to Dr. Goshen and what I knew at the time was the guidelines for treatment for this problem, now we're talking 1995. It's a very different time and function. The genome project was not complete. I was still looking at. For everybody listening, if you type in PubMed, I used to pull that up on a CD for all you people who remember what a CD is and load them in a computer. And that's, you know, I still use the periodic table when I was in medical school. So obviously, you know, now we have a genome project done. Computing is caught up. Things are much different now. We have the introduction of artificial intelligence and we have someone with the, I would say vision and compassion and empathy to put this program together like Dr. Goan has put together so that you know, someone who, you know and I'm, it's not to be critical. I have a lot of people come to me and just like Dr. Goshen, we can talk a certain way and that's. He mentioned nomenclature. So that's what doctors use a lot to describe a specific treatment. I don't ever say big words to patients because they don't help convey my thoughts about a problem. And so I always keep all of my discussions as simple as possible so that I can make sure that. And Dr. Goshen does this as well to convey properly what we're trying to say so that people understand it and they feel comfortable with what we're saying. So that then as they go through a very complicated process over that three to four month period where they're aggregating or putting together all of your data from all of your different appointments and all of your different providers and all those things that are super confusing to you so it can be summarized. That's an incredible tool. What I would say during that period of time and Dr. Go shake and agree or choose to disagree. I tell people like this is the time frame where if you're going to make some behavior modifications, These are your 3 to 4 month window to learn about and understand the quality of the air, the food and the fluid that's going in your body and the products you're putting on your body. If you change many of those things you're going to put yourself in a better position to be cared for by Dr. Goshen's team or any other team that you're working for. So I mean that's an amazing amount of information that Dr. Goshen has described. And we haven't even got into the nitty gritty of a specific individualized treatment for a protein that may be found. Maybe you can give like a simple example of that that everybody can understand. Like, what if we do all this, three to four months of work and we have a cancer that's resistant like my mom's was, but you find one thing to treat. Can you describe maybe just a vignette about that?

Yeah, that will be easy. You know what? I'll stick to a similar patient that approached me, approached us, very well known doctor, physician. She had atrial palpitations, atrial fibrillation. She went to the ER in a very big hospital in the west coast and they identified that it's an atrial fibrillation. And she was asking in the emergency room, she felt pretty much okay. She asked the fello in the ER to put an oximeter on a finger so that she can look at the O2 oxygen saturation. And it was a little bit low. So she called him and said, it's about 90. Maybe we should rule out what is common with atrial fibrillation, that there are emboli, like small particles of a clot that are being sent through the blood to the lungs. And they did a CT scan on her to rule this out. When they did a CT scan, they ruled out this emboli, but they saw that she had a big mass in one breast and a big mass in the axilla in the other side. So the whole picture has changed. What is that? They biopsied it and they told her that she had the aggressive type of an ovarian cancer. It's called high grade serous adenocarcinoma. You see how confusing are the words? But it's the most common aggressive type of ovarian cancer. Of course they saw that she has an ovarian mass. And they did.

They also, as soon as they do the CT and they see everything else, they're like, well, we better check the rest of this out.

Correct. So they gave her chemotherapy. They gave her chemotherapy because the guidelines today say that we used to with chemotherapy. Again, we have big names for this. It's called neoadjuvant chemotherapy, but it's just chemotherapy before you go for surgery. And her markers, her cancer markers were very high. Her CA125, which is the most common marker for this type of cancer, was very high. And she got three cycles, three treatments with this chemotherapy. Nothing happened.

Yeah.

And then she called us and we said, something is very Strange here. I mean, that's. No, not how ovarian cancer usually starts. It doesn't start with a metastasis to.

The breast and a metastasis always abdomen, typically.

It's typically abdomen. It can go to the lungs, but not too soft to solid organs outside of the. And the fact that it does not even respond to chemotherapy. Usually these cancers are very responsive. Unfortunately, they come back, but it's very responsive to the first chart of chemotherapy.

Oh, Dr. Goshen, you're going to say wrong drug, because drugs work when they actually are treating the right thing, typically.

So we said, you know what, it's not in the guidelines to sequence ovarian cancer. You don't have to sequence it by the guidelines, but let's sequence it. And she said, would you do that for us? And we will. And we did it, of course, very simple. And it came back quite strange. We saw that the most common mutations, changes in the DNA that are known in this type of ovarian cancer are not there. On the other side, there were. There was another mutation which is very uncommon at that point in time. We told him, why don't you discuss it with your medical oncologist and show it to him and see if he thinks that this is strange? And he definitely said, this is strange. And we told her, why don't you offer to look at the pathology again? And we sent the pathology from the west coast at that instance to MD Anderson. And it turned out it is an ovarian cancer, but it's not the high grade one. It's a low grade. Now it sounds like, okay, low, high grade. No, no, no. These are two differently, totally different diseases.

Say why that does not respond to chemotherapy. So everybody understands that.

So low grade serous adenocarcinoma does not respond ever to chemotherapy because it's low grade, it's a low grade and it's controlled by hormonal mechanisms. So it responds to hormonal treatments and to another type of drugs, which is called paroxyn kinase, but it does not respond ever to chemotherapy and it is a totally different disease. While unfortunately, the median overall survival of patients with high grade is a couple of years, around four years. This one goes for 12 years. It's a slow growing tumor and totally different treatments. Chemotherapy does not play. But this is. One has to understand it's not because she had a great doctor, but great doctors. You know, he gets a pathology, he follows the pathology. That's it. Start the protocol. From that time onward, he is scheduled to see the patient every like Three months, four months, and to see how she's responding to the chemotherapy and go ahead with it. And that should be reviewed as soon as possible when you embark on, on your cancer journey. I think if there's one thing that I want to leave your listeners with is the issue of regret. Think about regretting, making a decision a couple of months ago, just because you did not know that there are other options. Managing regret, generally speaking, in our life is tough, but managing regret when you're fighting for your life, this is awful. You want to be or many patients, not all patients, by the way, not all patients want to take an active part in their decision making. Many want to delegate it to somebody else. But I think the audience of this podcast and your audience are people who are very interested in being involved in what they decide about. And so if you do want to actively participate in the decision making, you want to make sure that you know all the options. You leave no stone unturned, upside down. That by, by the way, that does not mean that you are not going to make a wrong decision. But it's different managing a wrong decision that you made with your own considerations, but not because of lack of knowledge. Lack of knowledge and making a wrong decision, that leaves one with a lot, just the patient, also the family with a lot of regret issues. That's what we want to abolish from this world. No regret anymore.

Absolutely. I think during training I learned hard lessons early. Like as a surgeon, if we didn't identify a tumor from a symptom or a complaint, like using my mom's example of abdominal pain, like, I mean, all of the imaging is available for this, just like the patient example, all the imaging is there. But then the tactics didn't match the strategy. The strategy is to eliminate the cancer always. Whether it's through multimodal therapy with chemotherapy, radiation therapy, surgery. Obviously I trained as a surgeon, so I did a lot of surgical oncology for many, many years and then reconstructive surgery as a plastic surgeon, and certainly the term neoadjuvant for everybody. So that just means giving chemotherapy to the patient in the hopes that a tumor will retreat, regress, decrease in size to make it a operable tumor, if that's possible. And you know, to hear a story like that, it is disheartening. And many people will, I'm sure, comment on my show and ask me why I didn't meet with you about my sister. Well, my sister, if anybody knew her, her very strong willed person, and she made her own decision, she was not super interested in Western medicine. And although she did many aspects of it, when she originally had breast cancer, they gave her the NCCN guidelines and she got doxorubicin toxicity, had a cardiomyopathy and had to stop. So, you know, it takes one instance, not a, you know, that's a known consequence of treatment with that. That drug. Obviously, it was explained to my sister, but it nearly killed her. So you weren't going to convince her to, you know, embark on another journey of a drug getting injected into her, because she had already had that experience, which is obviously one that's always going to sit in your insulin in your brain and bring it back to like, oh, my God, I. I had pericarditis. I couldn't, you know, I felt like I couldn't breathe. I felt like I was having a heart attack. Basically, that's what was going on with. With her. And that happened for, along a lot of patients on doxorubicin. And for all that's good, that's a, you know, a consequence of it. So I think to. To summarize it, Dr. Goshen and his, you know, emphasis on genetics is. It's fascinating because I make this big deal about genetics. Both Dr. Goshen and I are old enough to know that genetics was taught pretty poorly in college. It was about Drosophila fly experiments and eye color, which I thought I was going to flunk out of genetics, honestly, in college, because I was so, like, being taught by somebody who was a supremely brilliant researcher but not a teacher. And so I think what Dr. Goshen and his team have done is really distill down something that's. It's a very complex, whether a treatment protocol or aggregation of data into something that is going to be a usable tool for patients and their families so they can better understand what's going on and lead them. Like you said, hopefully all the decisions become hopefully, a little bit simpler for them to make, but it surrounds them with enough information in a digestible way so they can actually make an informed decision, which is always when people hear me talk about, like they say, are you ever going to downplay the use of implants? I'm like, okay, so everybody listening. Whether it's a hip implant, breast implant, knee implant, dental implant, neurologic implant, hardware for broken bones or for some structural abnormality, implants are not going away. Just so everybody understands we need to do better about informing our patients about the risks and benefits of that. And so when you speak to something like Dr. Goshen, is he's really helping expand how you make an informed decision in a way that's most meaningful for you and your family. So Dr. Ghosh, I really appreciate having you on this show. Do you want to give everybody an insight in how to get in touch with your team if they choose to?

Absolutely. You can see the log of the company that I am the founder of, but it's a big company today. It's called N1X10. Why don't you just log into www.n1x10.com or just email me at ran. That's my first name. R A N1X10.com and I promise to you that I will be getting back to you if you mention this podcast within a couple of hours.

Thank you for coming on the show and we'll put all that in the show notes. I think everybody, you need to understand like this is the way forward and how we think about things in terms of genetics we talk about in my clinic all the time with functional genetics, toxicity, gut health, hormonal balance, lowering inflammation, improving the quality of air, fluid and food that you put in your body, the quality of the products you apply to your skin. Please be careful and take care. Thank you again. Dr. Goshen, thank you so much.

Thank you very much. My pleasure.

Thanks for joining me today. I hope you found the information and stories shared on this podcast helpful and informative. Remember, taking control of your health and wellness is key to recovery from breast implant illness. If you're looking for additional resources and support, be sure to visit our online store, Dr. Rob's Solutions at drrobsolutions.myshopify.com you'll find a wide range of wellness products and supplements to support your journey to recovery. From specially formulated detox supplements to personalized skincare products, we have have everything you need to aid your recovery.

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