SPEAKER_01 0:08

Welcome to a fresh face in hell. I'm your host, Jonathan Evan. Every week we talk to someone new and interesting, somebody intellectually curious, somebody who will hopefully renew our faith in this cold, cruel world we live in. A fresh face in hell. So you go back a few decades and it seemed like a cancer diagnosis was basically a death warrant. But we've come an awful long way in treating cancer in the 21st century. I know like dozens of people at this point who have survived stage four cancers of various types and are now cancer-free and thriving. Still, there is no universal cure for cancer. So how close are we? Why is the cure so elusive? Is there something the public doesn't know about potential treatments? These are just a few questions I want to ask today's guest, Dr. Amit Garg. Dr. Garg is a hematologist by trade and by nature a force for positivity in the world. You can find him on IG at BloodDocDad, where he reminds us daily that life is precious and that we ought to make the most of it. He offers tips on cancer prevention, dispels myths about cancer, offers us a peek behind the curtain as a hematologist, but more than anything, he encourages us to live our lives to the fullest. And that's a message we can get behind around here. So, Doc, thanks for being our fresh face in hell this week.

SPEAKER_00 1:35

Thank you for having me today.

SPEAKER_01 1:37

So, you know, being an oncologist, I cry a lot and I'm an empath. So like I I kind of take on everybody's baggage. Somebody tells me their sad life story. I can hardly sit on a city bus because I just I look at around and I'm like, when's the last time they cried? Um, being an oncologist seems like an emotionally taxing job. Like everything is life and death. Why'd you decide to become an oncologist instead of say a podiatrist?

SPEAKER_00 2:02

Good question. So I actually get that question often about, you know, why oncology and that it must be very sad. You know, there's actually new data that came out from the American Cancer Society that said patients are actually living longer with cancer today than they ever have before. 70% of patients live to five years. And, you know, that's a huge number when you actually look back, you know, 20 years ago, and that number was probably closer to 50%. So I picked oncology pretty much because there's new breakthroughs on a daily basis. You probably hear about it on a daily basis that this drug has been approved in prostate cancer, this drug has been approved in pancreatic cancer, or there's new data in pancreatic cancer of a drug that recently doubled survival. It's currently not FDA approved. But really, at the end of the day, there are so many new treatment options, new forms of immunotherapy, targeted treatments that are allowing patients to live longer. And living longer means better quality of life and living with their loved ones, spending time with their loved ones.

SPEAKER_01 3:17

So I like to make this just for our listeners, I like to start with basics. Um, because I don't like to get too far out and then like, I mean, what is cancer? I mean, how has it evolved over time? That's a basic question, but like I think one that people don't completely understand.

SPEAKER_00 3:34

Yeah, and I get this question daily from patients. You know, our cells are constantly dividing. So we have so many different cells in our body. We have lung cells, we have kidney cells, colon sand cells, and they're constantly dividing. And we make mistakes. Okay. Our DNA replication, there's mistakes. There are mutations, um, there are abnormalities that occur, and our body is constantly fighting that and addressing that and realizing that these cells have mutations and they should die off, something called apoptosis. But cancer is very, very smart. Cancer is very smart, and it finds a way to evade that. It finds a way to hide, to find different drivers. And so that's why cancer continues to sometimes grow. And that's why more patients are being diagnosed with cancer because they're living longer. So it's basically an abnormality in DNA replication in mutations. And sometimes, if that occurs in something called an oncogene, a cancer takes off.

unknown 4:39

Wow.

SPEAKER_01 4:39

So you answered a whole bunch of questions I had. Uh the next one was why is cancer so elusive in terms of treatment? And that's because it sort of constantly evolves and mutates. Is that right?

SPEAKER_00 4:50

Yeah, and cancer is not just one disease. You know, if you look at my comments sections of my posts on Instagram and TikTok, the naysayers, the trolls, their biggest statement is why isn't there a cure? We've spent billions of dollars. We've given billions of dollars of our tax money to NIH funding. Why is there not a cure? Well, there isn't a cure because cancer isn't one disease. It's hundreds of diseases, hundreds of subtypes. Think about breast cancer today, lung cancer, colon cancer. There are so many subtypes, so many different treatments. And the most important thing is to know that one person's breast cancer, colon cancer, lung cancer is not the same as another. We practice precision medicine today, precision oncology.

SPEAKER_01 5:43

So a breast cancer cell looks different than a hematoma or whatever. Like I think we all kind of labor under this misapprehension that a cancer cancer is just cancer. Like, you know, like we can just identify this certain thing. Hey, that's a cancer cell, but they look different.

SPEAKER_00 6:02

They're they're totally different. They look different underneath the microscope. Um, their DNA makeup is different. There are certain mutations that are upregulated or mutated in in different cancers. So you may have, say, a patient with, you know, I'm a hematologist, and that's basically a blood cancer doctor, uh a blood doctor. But the blood cancers that I treat, lymphoma, many different subtypes with different treatments, different algorithms. And the reason why they're different is because you want patients to live longer. If we did what we did 40 years ago, 30 years ago, 20 years ago, we would be treating all lymphomas quite similarly. And they and the more aggressive ones would only live like a year, maybe the non-aggressive ones would live a few years. But today, we're we're treating patients based on their molecular makeup of their cancer, and that's why patients are living longer.

SPEAKER_01 7:08

Okay, so what characterizes the cancer cell? How are they alike? You you explained how how how they all vary and they're different, but what what makes them cancer? What characterizes it as a cancer versus some other disease?

SPEAKER_00 7:22

Yeah, exactly. So the reason why it's categorized as a cancer is that there is uh some type of abnormality. There's too much production of one type of cell. And in cancer and oncology, we call that clonal. And that basically means that there's too much of one type. So if you have multiple myeloma, you have too many plasma cells, and then that could cause problems. In lymphoma, you have too many lymph cells of one type. They come from the same originating cell that has some driver mutation or some mutation in an oncogene that is causing that particular cancer.

SPEAKER_01 8:05

So that's it. They just always overpropagate. That's how you know that it's cancer, just because it because of the spreading. I mean, they always talk about how cancer spreads.

SPEAKER_00 8:13

So it's spreading, so it's it's it can be localized, it can be kind of spread to the local area, regional area, or a distance spread.

SPEAKER_01 8:20

But it's cells themselves are expanding and propagating.

SPEAKER_00 8:24

But the cells themselves also have a different appearance. So if you look at a normal breast cancer cell or normal lung cancer cell versus an abnormal cell, there are changes when you look at it, and a pathologist looks at those slides underneath the microscope, you see that um it has an abnormal appearance to it. There may be changes to the nucleus, the cytoplasm, changes that based to the on the naked eye look abnormal. And then the pathologist does additional testing, stains on those particular cells, which may be abnormal. Um there may they may do additional molecular kind of DNA-based testing on a sample, and that will give us more information. So it's not only that there's more of one type of cell, but that when you actually look at that cell and you do additional testing on it, you realize that it's aberrant. It's abnormal in some way. It has some features of the original cell, but it has all these other features which are categorized as criteria for a diagnosis of cancer.

SPEAKER_01 9:30

And so it's this abnormality in the cells themselves that make it so that the body can't naturally address it, right? I mean, so this is why this is kind of why it's so elusive, because the human body's so amazing. Like, I mean, our immune system and the way we get, I mean, the your body just knows what to do. Even some of our like weird physical habits that seem inexplicable, they're starting to realize that there's a reason you do that because of, you know, this or this, anything from a sneeze to whatever. Like, so is the fact that they're abnormal, does that mean then that the body's immune system doesn't know how to attack them because it's programmed to attack normal cells and it it's not it's not genetically programmed to attack abnormal cells?

SPEAKER_00 10:14

That's very true. The reason why cancer can become elusive, so we are fighting cancer on a daily basis. Our body is fighting cancer on a daily basis. So cells that are undergoing mutation that should be removed from our system because they're mutated. We don't want those cells to continue to divide. Our body recognizes them, our immune system recognizes them in the form of an antigen, and we recognize it and our body removes it. But cancer is smart. Cancer is very smart, and cancer finds a way for our immune system to not recognize it. Okay. And that's why the branch of treatment of immunotherapy has really exploded in the last seven to ten years, because that that way that cancer evades us, we found ways to block that with certain immunotherapy drugs. By blocking that, now those parts of the cancer cell can actually be recognized by our immune system. And Kutin can do what it's supposed to do, which is um apoptosis, which is eliminate that cell from our system.

SPEAKER_01 11:30

So then, like, would immunotherapy, that would be probably is that where cancer treatment has come the furthest in the past few decades?

SPEAKER_00 11:37

I think so.

SPEAKER_01 11:38

It's just this identification process. You said before that you're just kind of casting a wider net at it or whatever, and now you can narrow in on those abnormalities. And this is does this is this is this where the genomics come in? Like if you can see the specific abnormality and you're talking about blocking it, I mean, is it very close? I'm groping towards an actual understanding. I really want to understand.

SPEAKER_00 12:02

Like, yeah, and and I think it's and I think it's great. And I, you know, this is a great point that you're making. Uh, you know, uh, being on TikTok, being on Instagram, I patients are asking better questions. They're asking more detailed questions, they're asking questions about the science. And being in practice for 10 years, I rarely got these questions 10 years ago. So I think these are really important questions. But yes, the whole field of immunotherapy exploded because of drugs like K truda, Nivolimab that are used for lung cancer, that are used for melanoma, that's used for colon cancer. Many drugs, almost all solid tumors are treated with some form of immunotherapy. And the reason is you're harnessing your immune system to recognize the tumor cell as abnormal, as different, and and and activate your T cells.

SPEAKER_01 12:52

And then it can naturally your body will then naturally target on its own.

SPEAKER_00 12:55

Yeah. And then we it's expanded beyond that because you know, immunotherapy has evolved over time that now the form of immunotherapy that we're using in leukemias, lymphomas, multiple myelomas, something called CAR T or chimeric antigen receptors, these harness your immune system in a more uh specialized manner. They are targeting a particular protein that's expressed on uh myeloma cells, lymphoma cells, leukemia cells. So this immunotherapy is becoming more specific. And it is allowing patients to live longer. There was the approval of a drug called YesCarta back in 2017, and that was the first approval of a CAR T agent, and it was approved in diffuse large B cell lymphoma. And patients in third line, third line meaning they've been diagnosed with this lymphoma, it's aggressive. They get their first line treatment, they don't respond, they get a second line treatment, they don't respond, and now we have to give them something else. Usually these patients don't live very long, they live six months, maybe nine months. And the use of this drug, YesCarta, you know, allowed patients to live more than two years, and even a 30% of patients for the disease to never come back after 10 years. And so that's a that's a that was a huge milestone in the field of cancer, a huge milestone in the field of hematology. But this is all immunotherapy. It's a it's a very specific type of immunotherapy.

SPEAKER_01 14:39

So one sort of banal observation, but true. You cancer docs have got to be really good with the long multisyllabic words, man. You guys can just make this like six-syllable word, just roll off your tongue. Come on, give me a few. Give me a few of the longer ones that you had to master.

SPEAKER_00 14:56

Well, you know, it's it's yeah, it's it's really tough because some some people, yeah, everyone's I can't barely pronounce some of the words because all the drugs have such long names. You know, yes, carta, brianza, nilotnib, desatnib, immatnib, um, you know, venid.

SPEAKER_01 15:12

The diagnosis is themselves, like biochemoprusting.

SPEAKER_00 15:16

Yeah, so like just their diagnosis, you know, um acute myelcytic leukemia, acute myelomono, you know, uh chronic myelomonocytic leukemia. There's it, there's a lot of verbiage.

SPEAKER_01 15:27

And you actually don't realize, I mean, that takes skill. I know, again, it's kind of a banal observation, but I've yet to meet an oncologist that is not very conversant and like they always just come out like I don't know if you guys have to practice or no, you know, I I I don't know.

SPEAKER_00 15:42

A lot of the oncologists and hematologists that I follow on social media, they're able to, I think, just take a topic and address it. I just feel like that's how we were trained. I feel like radiation oncologists are like that too. You read a lot of data, you have to assimilate that data really quickly. And, you know, that's what the goal of, you know, being on social media is it's let's uh, you know, let's sum up something in 20, 30 seconds. You know, someone else can read the whole article if they want to. Someone can go to the original article in Nature or New England Journal of Medicine, but you know, maybe highlight in 20, 30 seconds what's so important so that the general public can know. So there was, I mean, you probably heard about pancreatic cancer, a huge breakthrough that happened in pancreatic cancer recently.

SPEAKER_01 16:28

You may I know about pancreatic cancer. I don't know about the particular breakthrough.

SPEAKER_00 16:31

Yeah. So pancreatic cancer is an aggressive cancer. And uh the reason why it's aggressive is many times it's diagnosed at later stages because of where the pancreas is located. It's sort of deeper down in the upper abdomen. So many times when there are symptoms, usually patients are diagnosed with stage four disease. But stage four pancreatic cancer today has a survival of less than 5% at five years. So if you have metastatic pancreatic cancer, your survival is not good. It's less than only less than 5% make it to five years. So many patients pass. But there was a drug, um, it's called a RAS inhibitor, Derax and RAS inhib, and another mouthful. And recently at the oncology conference that I was at in Chicago, it's called ASCO, the biggest, largest cancer conference. The last abstract presented was this new drug used in second-line treatment, where treatment should only work for about six months. It actually doubled that. Instead of six months, it went to 13 months on average patients respond to this drug. Huge, huge uh breakthrough because RAS is a very difficult target for many years for there to actually be a drug that targets RAS. But then at the same time, you know, huge breakthrough in this space where you expect patient to get first-line treatment, and then a second line treatment, if we even offer them chemo on average, it's less than six months. This drug is, you know, doubly, doubling that. And so it was that's exponential.

SPEAKER_01 18:14

Maybe you'll take another leap.

SPEAKER_00 18:16

And then exactly. And then can we use this drug in other spaces like lung cancer, colon cancer, you know, other because RAS is a is a driver of cancer uh in general. But these are some of the huge breakthroughs that we're seeing uh today. And and part of the reason why I think this is this is the field to be in. You know, more patients are living longer. There's a need for oncologists, there's a huge shortage of oncologists because patients are living longer. There are more, the incidence of cancer has increased because our testing methods have gotten better, they're more sensitive, we're doing more evaluations and you know we're doing more testing, we're doing uh blood tests to try to diagnose cancer. We're doing uh full-body MRIs. Not that these are recommended, but because of all of this additional testing, we are um there are more cases today.

SPEAKER_01 19:17

I will come back to the full body thing because that was a question I was gonna ask you later. But uh before I forget, uh this drug you're talking about for pancreatic cancer, again, inhibitor, blocker, this idea of treating something by inhibiting it or blocking it, it made me think of um, you know how like when you eat uh uh uh what do you what do you call it? When you have a when you have a uh antibiotics, how sometimes antibiotics they kill bacteria and target bacteria, but sometimes you will like get constipated or something because they actually kind of sort of broadly target bacteria, so they can also kind of wipe out bacteria that helps you in your digestive process or whatever. Does does this happen with the cancer medicines too, or are they way more focused? I mean, but or way more focused.

SPEAKER_00 20:03

They are more focused. So I think you were talking about maybe antibiotics change your gut microbiome. And so it definitely changes your gut microbiome antibiotics. But the biggest misnomer that I tell many patients are that even though I'm not giving you classic chemotherapy, so there's a you know, even another basic theme is treatment in cancer. People think everything is chemotherapy, but it's not. You know, we are using less and less chemotherapy today because we're using targeted therapy. We're using pills, we're using different injections, um, we're using different forms of immunotherapy. And so in some regimens, like myeloma, I don't actually use for many patients who are in their 60s, I don't use any chemo initially. It's all kind of targeted treatment. But unfortunately, these treatments have side effects. Um, and uh, you know, you there are different side effects. A lot of them affect the immune system. Uh, there's a whole new branch of immunotherapy called the bite antibodies, where one side targets the immune system, the other side targets the uh tumor. And these bite antibodies can cause a lot of something called cytokine release syndrome, where there's a huge inflammatory response, fevers, low blood pressure, sometimes confusion. And so I tell patients that even though this treatment is targeted, it's more effective. There's still a long list of side effects, unfortunately.

SPEAKER_01 21:35

So I read somewhere, I think, um, that unlike many diseases, only something like five to 10% of cancer cases are attributable to genetic predisposition, um, which is different than many diseases. Is it is this true? Is it does this mean that is cancer largely environmental?

SPEAKER_00 21:53

It is. It is, unfortunately. I five to ten percent is is is probably a little a little more liberal. Um There are certain genetic factors that increase your risk of developing cancer, braca mutation, a mutation in something called TP53, lean from many mutations. There's different mutations increase your risk of stomach cancer. But they make up a small portion of cancers. And the question the patients always ask me is that, you know, will my kids get this? You know, that they get this from my parents. And it's for the most part, it's unlikely.

SPEAKER_01 22:26

Um but there could be a genetic predisposition that your body might environmentally be more uh welcoming to cancer, right? Like because of because of some other condition you have, it might make you more susceptible to getting cancer.

SPEAKER_00 22:41

So if you have lymphoma or you have something called CLL, which is a chronic lymphocytic leukemia, these all fall into kind of uh lymphomatory, non-Hodgkins lymphoma. They've done studies showing that if you have this, the likelihood of a first-degree relative developing lymphoma is increased. You know, maybe that risk has increased by 15 to 20 percent. It's increased. There's no particular uh mutation abnormality that we can test for, but a lot of a lot of studies have shown that increased propensity. So there's probably some genetic component to there, but there's not something that we can test for like BROCA 1.

SPEAKER_01 23:25

Right, because it's not specific to the mutated cells themselves. It's just it creates an environment in the body that may make it more Hey, I'm starting to get it a little bit. But you know, you're for your 12 years of school and I'm a budding oncologist.

SPEAKER_00 23:39

You great knowledge base. But you know, the first question that you asked was, you know, how much of it is our environment of, or is it what we do to our own bodies? And, you know, the last thing an oncologist wants to say to a patient is, you did this to yourself, you caused this. And and many times I don't, because no one truly knows, you know, what portion contributed because of the smoking, you know, to the cancer? What component was the alcohol? What component was the H. pylori infections? What component are the autoimmune diseases, rheumatoid arthritis, lupus, dermatomycitis? You know, what component contributed to that cancer? But the American Cancer Society have done studies looking at this and they have put out numbers saying that uh 40% are due to preventable causes out there. HPV, getting the HPV vaccine to decrease your risk of developing cervical cancer, head and neck cancer, you know, stopping smoking. You know, if you stop smoking for more than 20 years, your risk of lung cancer is kind of similar to someone who hasn't stopped smoking. You know, obesity. Obesity associated with 13 different cancers. Um, you know, why do you see all this data out there about the GLP1 drugs, uh Zempic and Wagovi? Uh, why is there all this data showing decreased cancer rates? Well, it's because obesity is associated with cancer, the insulin resistance. So there's a whole slew of preventable uh risk factors that are contributing to to cancer as well. But you don't know how much each is contributing because there are patients that never smoke that got lung cancer.

SPEAKER_01 25:24

Yeah. Um, so it's it's hard to say that and I know like 85-year-old guys are still choking down heaters and they've never had it either. So, like some people just seem to have uh maybe it's just luck, or just maybe it's something about their genetic or immunal immunal makeup that makes them more resistant to cancer cells.

SPEAKER_00 25:44

And John, I I think that that that is exactly the point. That is exactly the point. There is a whole area of oncology that we don't know. Because how do you explain someone who's been smoking since they were a child and now they're 80? Um, and then how do you explain a 40-something-year-old Asian woman who is diagnosed with metastatic lung cancer with an EAGFR mutation? Um, there are components of your immune surveillance. There's probably certain genetic components that we don't know about yet. Um, and so I think this this whole field will continue to grow. And then I think eventually where we're gonna get to, and this may be a question of yours, is that we're gonna move from the space of treatment. We're gonna move from the space of diagnosis to space of prevention. Yes. And so I don't think I hope in my lifetime we get there, but I think that there's so many barriers. There's so many barriers. And I think one of the largest barriers is cost. It's these cost-effective analyses. It's it's um, will this test so you know, take for example um the gallery test? You've probably heard of there's blood tests out there, we only screen for five cancers. Should I get this blood test that costs seven, eight hundred, maybe a thousand dollars, and it will pick up a signal for pancreatic cancer, or I'll pick up a signal for colon cancer, and then I should go and then get additional testing. Should I have that test done? Well, they just did a really big trial in the UK and they took 50-year-olds who are asymptomatic, have no symptoms, okay? And they half of them got this test and the other half of them didn't get this test. And what the UK said was if this test met its primary endpoint, we will then give this test to everyone in the UK above the age of 50. And then, you know, Gallery was like, oh, wonderful, like this will be a huge and so they did this test, and what they found was that it didn't uh it didn't make patients live longer. Okay. That was one thing. And then it statistically didn't decrease uh stage four cancers. So isn't the whole goal of catching it early so that we don't develop stage four disease? But if this test is not doing that right now, is this the good test to approve? Is this a good test? I know that decision will come later this year.

SPEAKER_01 28:20

Is that because, sorry, is that because again I'm trying to understand, is that because this the test itself is sort of broad, and you've been explaining that everybody's biology is actually so personalized in a way. Is the problem that the test is very broad? So you're screening, you're casting this wide net, but everybody's specific biology is going to maybe make it harder for the catch to test, or I think that might be a component.

SPEAKER_00 28:46

I think I think the other piece is that the technology is not there yet. It's not as sensitive as it should be, it's not as specific as it should be. It's not there yet. But what I'm but this whole piece of prevention, I think we'll get there. We will get there. We will get to that point where these tests become so inexpensive that these tests become so sensitive and accurate that why not start doing these tests in your 20s or earlier? Because we are finding patients with younger cancer. There's another blood test that was recently approved for colon cancer. So we screen for colon cancer. We can do different types of tests. We can do a colonoscopy, we can do a sigmoidoscopy, we can look at uh stool DNA, we can look at just stool blood. Some are more sensitive than others. The most sensitive for colon cancer and polyps is the colonoscopy. But there's now a blood test that's out there that will screen for colon cancer as well.

SPEAKER_01 29:46

And it's made for people that don't get colonoscopies who can I do that one because I'm I'm listening and you're gonna get you're gonna be mad at me because I'm 58 and I haven't done it yet because I'm just terrified of having that balloon pumped. I just I I I mean you can understand, right? But like I gotta do that. Is the blood one an option for me, or would you recommend that I actually do the whole go in and you know, have somebody drive me there and drive me home?

SPEAKER_00 30:11

Still today for detecting colon cancer, colonoscopy is the most sensitive. And for picking up polyps, which are pre can be cre precancerous, still today the recommendation is colonoscopy. But then there's like 30 million people out there, millions of people who don't get colonoscopies. Do you think it's better to have them actually do a blood test than do nothing? Probably.

SPEAKER_01 30:33

And so if it's a colonoscopy, I should just go the full Yeah.

SPEAKER_00 30:37

I mean, I think that's what's recommended, but you know, there's gonna be a role for this test.

SPEAKER_01 30:41

But it's already You can't just get on YouTube and do a tutorial with this. Like I've been doing a lot of mechanical work lately, just using YouTube tutorials and like getting the right socket rent since I can't just, you know, headlamp, close friend, anything like that. I don't know which close friend would do that, but yeah. Well, you'd be surprised. I got a lot of good friends. Um, let's talk about some of the the myths. I know one of the big things you do on your on your IG page is dispel myths. Um, and you had mentioned eight HPV earlier. Is that a myth that you can actually contract HPV from Cunilingus? I mean, I that may sound like a ridiculous question, but like that was a thing. I I think it was Michael Douglas, remember, you know, there was like people were saying, well, he got that from Cunalingus or whatever. That that I'm assuming that's a myth.

SPEAKER_00 31:29

That is a myth. That is a myth as well. You know, the um Yes. You know, HPV increases your risk of cervical cancer. And since the United States Preventative Task Force, Services Task Force has recommended getting the HPV vaccine at the age of 11, 12, you know, cases of cervical cancer have have have have plummeted. And and so it is um decreases the risk of cancer. And it's not just cervical cancer. We're talking about for men uh and boys, anal cancer, we're talking about um uh head and neck cancer as well. And so these are all uh decreased. But yeah, myths, myths. That's one of the biggest things I do. And I think that's the reason why I'm on social media is because there is so much misinformation out there. And and I am shocked, I'm even shocked this week. Uh, you know, I posted this video about uh sugar and cancer. And, you know, just the fact that many influencers out there are giving incorrect information. They're telling patients who are diagnosed with cancer to cut out all carbohydrates and to cut out all sugar from their diet diet, as that will help their cancer, will control their disease, will, you know, cure their disease, will uh address their disease in some way. And what I see as an oncologist, you know what I see, John? I see patients go on a keto diet. These patients lose drastic amounts of weight, and then afterwards they have trouble getting through treatment. I have to delay their treatment, I have to drop their dose. It's because patients who are cacectic, patients who have lower body weight, these patients do worse. Trial after trial has shown the same thing. So you know what I tell my patients? I tell them to eat everything. Eat anything you want.

SPEAKER_01 33:30

Yeah, that is that is one of the things, you know. I I went through stage four uh oral cancer with my mom, and I was her caregiver, and um, you know, she didn't do she did targeted radiation rather than uh chemo. Um lost her mandible on one side, seven teeth, lymph nodes. It was a big deal. And she was 88 at the time, and the oncologist was just amazed that she got through it so quick. But that was the that was one of the things they said. Like they give us like a 30-day runway before we were gonna start the treatment, and they're like, You got to get some meat on her bones, you got to get some meat on her bones. Like, and so that was, and I'm still trying to get her to raise weight. I mean, she she cleared it, the cancer's gone, it hasn't backed, but as we know, it only takes one cell, so I'm always a little nervous. But uh, yeah, that was a big thing. It's like we need her hardier before the treatment, you know, because she was only weighing about 95 pounds, she's just very thin at this point, and so I'm like, man, it was murder, you know. I'm pushing like three insurers a day on her. I had to get her off the lean cuisines. She likes those microwave lean cuisines, and I'm mom, these things got like 180 calories. At least move the stove for her.

SPEAKER_00 34:33

She wouldn't eat my home cooking, but um so yeah, she just eat ice cream, eat donuts, eat pizza, eat what you were eating before. You know, I'm not telling you to do this for health for the rest of your life. Do it while you're getting through treatment. And so, you know, the reason is you're only gonna get that outcome. You're only gonna get this cured if you have localized disease, if you get the treatment that you're supposed to get. If you can't even get the treatment because you're not strong enough, you're losing muscle, you're losing weight, then you're not gonna get that outcome at the end. So, um, but yeah, it it got a lot of backlash on the online community because no one wants to hear that. No one wants to hear an oncologist say it's okay to have some sugar.

SPEAKER_01 35:17

My kid's dermatologist said the same thing. That was a myth of dermatology. She said there's not actually been a study that is proven that sugar, you know, I kind of intuitively makes sense. Like maybe it wouldn't mess with your pH balance or something and cause acne, but apparently that's so let's talk about some of the major myths of cancer that you hear again and again. I brought up the HPV one, but I what are some of the most widely uh you know perpetuated myths about cancer that you you just get all the time and you have to say no, not not the case.

SPEAKER_00 35:48

So other than uh sugar and cancer, the mammogram. You know, the mammogram is not safe because it is you're exposing you to radiation. Study after study after study, large trials, meta-analyses have shown that mammograms uh catch cancer early and have women and men live longer. Okay, it makes you live longer, it decreases the risk of death from breast cancer. There is a small risk of radiation, but that risk of radiation is not very different than flying on a plane or certain number of days of background radiation just living.

SPEAKER_01 36:30

Or yeah, just laying on the beach for six hours.

SPEAKER_00 36:33

100%, 100%, or even just the radiation exposure, like if you took a long plane flight from, you know, the the West Coast to the East Coast. And so the risks are so small and the benefits outweigh the risks. Get a mammogram, get screwed.

SPEAKER_01 36:48

Yeah, good to know. And and so then how does this relate to the thing about um body scans? Is that one of the things why people are don't think body scans is gonna is it is it the exposure to radiation, does it or is it because it just creates more unnecessary tests and procedures? Why is there why are body scans uh controversial?

SPEAKER_00 37:06

So the MRI doesn't have radiation exposure that you would see with a CT scan or a PET scan. So we don't worry about that. But the data is not there, John. We we just talked about a blood test to screen for cancer. You know, now we're asking to do a full body MRI. And the data is not there. It's not telling us that patients will live longer. It's not telling us that there'll be decreased stage four cancers. There's just there's just no data for it. And then what can it lead to? It can lead to unnecessary testing. You know, majority of these full-body MRIs pick up something in the brain, in the kidney, uh, incidentally in the lung. And you can't just let it go. You can't you can't just, you know, not test it. You have to do additional testing. And by additional testing, I mean imaging, maybe biopsies. Some of these biopsies can lead to adverse events, they can lead to a pneumothorax, they can lead to a colonoscopy causing a perforation, you know, they can lead to, you know, a cyst hair that's uh needs to be biopsied and that causes it to bleed. So, you know, a lot of this testing can lead to uh additional uh side effects or adverse events.

SPEAKER_01 38:20

You know what a big one is we haven't talked about yet, a side effect of all this testing?

SPEAKER_00 38:24

Money anxiety, man. Yes, my yes, yes, thank you.

SPEAKER_01 38:27

Friend of the podcast, Ellen Vora, who's the author of Anatomy of Anxiety. Um, she said that like between 20 and 30 percent of healthcare spending is on unnecessary tests and procedures for people with health anxiety. Um, you know, people that are maybe a little bit hypochondriacal or whatever. If I Google cancer once, my algorithm is just gonna be a flood of doctors telling me to watch out for these symptoms and stuff, you know what I mean, which creates more anxiety, or I get a bunch of ad from companies that are selling me full body scans. So how how would you suggest navigating all this fear?

SPEAKER_00 39:01

Yeah, that's that's tough. Um, you know, I think fear will always be there when a doctor or an oncologist finds something on your scan. I think one of the main things that can be done is to let your physician know.

SPEAKER_01 39:14

I think uh, you know, there was recently But then to know that you're it you have an anxious anxious disposition?

SPEAKER_00 39:20

Anxious uh health anxiety, that your blood pressure gets higher when you come to the office. Because I think one of the ways to combat that is with clear communication. You know, it may not completely go away, that health anxiety may still be there after talking to the doctor, but you know, coming up with a plan, coming up with a clear plan, understanding the risks and benefits about what we're doing, what we may find, I think is very important. There are patients that I have who it doesn't matter what I say, what we talk about. You know, whether the evidence shows that doing the CT scan six months from now, 12 months from now will not make any effect on your outcome, if uh but patients still want it. So even sometimes with that discussion, it may not alleviate their concern. The only thing that will alleviate their concern is a scan, even though there's going to be radiation extra. Clean bill of health, really. Even though there's radiation exposure with that scan. Um, so I think, but having a discussion, having some clear communication and having your physician understand that's how you process the medical information, I think is super important.

SPEAKER_01 40:26

Yeah. Well, I mean, listen, I'm not knocking other doctors, but in my experience, you have a nice bedside manner, I'm guessing. I've noticed that a lot of doctors, like I went through this thing where I went down the rabbit hole where I thought I had a, what did I I thought I had a like a seizure or a stroke kind of thing, and I had a bunch of bastion of tests done, you know, the tilt table, all these tests and stuff. And like only I like only two doctors out of like maybe 11 or 12 really had had this sort of, I think it's an underrated facet of of being a medical doctor is just the the sort of empathic nature and understanding and patience. I mean, I can see why people would be kind of impatient as a doctor, they got a huge caseload, a clipboard, you know, 30 pages on their clipboard, they got to make the rounds, they're working weird hours. But like I've noticed that a lot of, I mean, like maybe more disproportionate than say, um, like uh, and I think it has to do with stress probably and and pressure, but like if I were to take a cross-section of uh baristas versus doctors, I find that a higher percentage of doctors have maybe not the best interpersonal skills. And you would think that that would be something that would be so important, like just like comforting the being realistic and saying, like, this is the diagnosis, but being able to talk them off that ledge and and make them feel safer seems like such an important thing. But like just I've just found a lot of doctors seem to be missing that.

SPEAKER_00 41:54

I think it also depends on the specialty. You know, there's you know, specialties like ER and ICU, where you don't spend as much time with patients, you don't follow them longitudinally, like say an oncologist or a partner.

SPEAKER_01 42:06

Okay, good. That's a good point. Yeah.

SPEAKER_00 42:07

So that's, you know, one point. I think the second point is, you know, just being on social media has like really highlighted, you know, what goes on out there, what what really goes on wrong out there and how many things are missed and how many patient, how many, how patients feel about their oncologists, how do they feel about their communication style? How do they feel about whether they listen to them? So I almost feel like being on social media over the last three years have actually exponentially improved my patient satisfaction scores that I the organization I work for keeps because I see what's out there. I feel like it's actually changed me for the better. You know, I feel like being more present and listening to all the complaints, because a large portion of my following are patients or family members of patients. You know, the other half are medical professionals, but I almost feel like sometimes in certain silos, some physicians may not know that that's how they're being perceived or that how that's how they're being cut, they're they're coming across.

SPEAKER_01 43:09

So I wanted to talk about uh uh clinical trials for a minute. So um are clinical trials generally are these, it seems like they're like cutting edge. Is that because a lot of the times you're using a treatment that is not yet FDA approved, but you're kind of like signing a waiver like this is we don't know yet, but we have persuasive reason to believe that this aggressive treatment might help. It's not actually FDA approved. Is that kind of how it works with a clinical trial?

SPEAKER_00 43:36

Yeah, everything that we do in hematology and oncology is based on a clinical trial that was done previously. Everything is evidence based. So the way we practice today, and even this recent trial that showed a doubling in survival and second line pancreatic cancer was based upon a clinical trial. Now, clinical trials are really rigorous. Meaning that they're the way they make the clinical trials, design the clinical trials, is to optimize enrollment in those clinical trials. And so you really don't want to make them, the two arms, so different that people would not want to, or patients would not, or physicians would not want to enroll on that clinical trial. So many times trials have the standard of care what we would normally use. Okay. Well, we normally use. And maybe in this arm, it's going to be what we normally use, but maybe we'll add an additional drug. Okay. And so at least we know you're going to be getting the standard of care, but maybe something extra in this arm. And yes, there's probably some other phase two data, some phase one data, some previous data that shows that this extra drug may be beneficial. And then when the trial starts, they do interim analyses. And if it's already showing quite a better benefit, a huge survival benefit, progression-free survival, whatever it is, in this other arm, then the trials are usually stopped early because we're they're like, wow, this particular arm is doing so well. This side of the clinical trial is doing so well that we have to stop this trial and give everyone on the trial this particular drug. And then we need to go to the FDA, you know, if this is a phase three trial and get it approved because it's the results are so great. But unfortunately, a very small percentage of patients enroll in clinical trials. Um, it's it's somewhere from 7 to 10%. I think the data is 7% of eligible patients actually enroll on clinical trials.

SPEAKER_01 45:43

That surprises me. I would think it would be just the opposite. I would think that 93% would be like, sign me up, man.

SPEAKER_00 45:50

But think about it. Think about it, John. Where are most of the patients in this country in the U.S.? They are not near a major medical center. Many of them are not here in the Bay Area. They may be in rural Idaho, Minnesota, they may be in Louisiana. That's just one component.

SPEAKER_01 46:06

Okay, but then but then then they probably don't even really have access to those clinical.

SPEAKER_00 46:10

So I think access is one. Second is access from the oncologist standpoint. You know, I work for a huge institution that has a very robust clinical trial program. But if I'm a private practice oncologist in um south of Chicago, and it's just me or some other guy, and we don't have any clinical trials, we don't have any programs there, you know, will this individual drive an hour, an hour and a half, two hours to Chicago to get a particular clinical trial? Maybe not. So that's access from the patient perspective, access from the oncologist perspective. And then I think it's the whole third piece: clinical trial designs. You know, not all clinical trial trials are designed this way. You know, if if it's always designed this way, you know, the pharma company may say, well, you know what, we're gonna spend $50 million on this trial. You know, maybe we this trial it won't come out the way it's supposed to. So instead of comparing it to the standard, you know, we know that maybe the guidelines give three sets of uh drugs that we can use. So let's use like a really like older regimen and compare it to what we're gonna use on this arm. So the trial design may not be so great. So some oncologists may say, well, this may not be beneficial for your patient. And then I think the last one, which is a huge factor, is distrust. I think there's a distrust in patients understanding.

SPEAKER_01 47:28

I don't understand that part.

SPEAKER_00 47:29

What clinical trials are, and I think it's a part of maybe sometimes it's history, it's race, it's experience, it's health anxiety, it's, you know, previous trauma in health care, their previous experiences with family members. And so there are clearly times when I tell patients that they would be a great candidate for this clinical trial. And they're like, thank you, but you know, I don't, you know, even though I tell them you're not being experimented on, you are this is standard of care, you may be getting something extra. Um, many times they still don't want to uh enroll. So, but nonetheless, the amount of patients that we enroll in clinical trial, if this is what we use to forge future guidelines, future treatment options.

SPEAKER_01 48:13

Um, it seems like the like one of the main pillars of advancement and treatment is these clinical trials.

SPEAKER_00 48:19

Like, you know, my wife's an ICU doc. She's an intensivist. And, you know, she is utterly shocked because you can go years in the ICU without a new treatment. You can go years in the ICU without a new protocol of any sort. And so it's this field is vastly different than many fields of medicine out there, because I can probably tell you, you know, what has occurred in the last week or two alone of a few breakthroughs in chemotherapy, in guidelines. And I feel like people are like, gosh, you always have something to say. And I'm like, it's not even like something to say, it's just my field. There's just so much content out there. There's just so much new data that's out there, and and it's ever changing, and and it's all helping patients.

SPEAKER_01 49:08

Two doctors. Fuck, man, you guys are loaded. I'll bet you, let me guess. You guys have got a great like a beach house in Casumel, but you never get to use it because you guys are both working 70 hours a week. And when you do get some time, it seems like a you know what I paid for?

SPEAKER_00 49:22

I pay all our all our money goes to our kids, our kids' AAU basketball teams, their coaching, they're swimming. God, I mean, kids are expensive, man.

SPEAKER_01 49:32

I know my kid, oh, 3D printers, anything. And I don't even have a lot of money, but like, yeah, I kind of jump it all into my kids because I want them to. When I grew up, it was like uh just going into the gift shop was it may as well have been a fucking museum, you know. So my understanding clearly limited, but it's probably doubled in this conversation. But haven't we known for decades that cancer cannot thrive in an alkaline environment? I mean, so so wouldn't like creating an alkaline environment in the body be like a fundamental wouldn't that be key to curing cancer? Or am I wrong there? Is that just old data?

SPEAKER_00 50:04

That's old, that's old news. That's also a big myth that I see out there because uh our body's blood pH can't change very much. If you if it does change, you're gonna end up in the hospital in the ICU. And so our lungs and our kidneys keep our pH in such a small window because if they don't, you're admitted to the you'll you're probably gonna be admitted to the ICU. So any amount of alkaline, you know, fluid you can take in will be addressed by our kidneys and will be addressed by our lungs in removing CO2, removing acidosis. And so there is no way if you're a functioning human being at home walking around, you know, that alkaline water that you're taking in, or that I forget even the name of it, the Cajun or uh Kegeen or some sort of device that's sold for thousands of dollars to make your water more alkaline. These are just grifters. These are really just people trying to make money. And you know, and so we a lot of my posts are about, you know, alkaline water, sugar, etc. But you know, the biggest thing that anyone out there can can really realize rather quickly on someone's post or someone's uh uh page is you know, one, do they identify their credentials rather quickly? If you're having really trouble of trouble finding out whether they're a physician or not within a few seconds of being on their page, they're probably not a physician. And the second thing, are they selling you something?

SPEAKER_01 51:41

Yeah, well, that that's yeah, are they directly? I'll start watching this interesting video and I'm like, and then I know it's I get five seconds and I go, oh, this is a pitch. They're not gonna really give me the answer. Yeah.

SPEAKER_00 51:51

Are they selling you a protocol? Are they selling you like a document, a PDF? Are they selling you a supplement? Are they selling you, and that's the third, that's a big one, also supplements. Supplements cannot prevent cancer, and supplements cannot cure cancer. Supplements are actually not FDA regulated. And so we actually don't know what are in supplements. So even if you take an iron tablet, which I recommend to patients, ferrosulfate, if you're iron deficient, we don't know a hundred percent where you got that iron from and how pure it is. And so then people are talking about all these other supplements that are out of it.

SPEAKER_01 52:29

And then there's the problem of absorption too. Like, I mean, just because you load yourself up on these supplemental vitamins and stuff, it doesn't mean your body absorbs them in a way that is actually that effective, right?

SPEAKER_00 52:41

Correct, correct. So we don't have the data that it prevents or it cures cancer. And then at the same token, we don't have data that shows how is it being metabolized? Is it how pure is it? And uh it is not something that we recommend. Now, I don't say anything to patients that want to take something after they're done with treatment, but I usually don't recommend any of these supplements during treatment because they can affect the metabolism of some of the drugs that I'm prescribing.

SPEAKER_01 53:08

Okay.

SPEAKER_00 53:09

And so we usually don't want any of that during that time.

SPEAKER_01 53:12

Okay, this may be another dumb question. I'm full of them. And I I think you've addressed this a number of ways, but I'm not sure you've exactly answered it because I really my goal here with this conversation is to really understand how cancer cells work as much as possible. But you know how when you learn to treat something or create a deterrent to say, like a virus or a pestilence in the environment, you know, like whatever locusts or whatever, that the target often adapts to the treatment and becomes resistant. Now, cancer adapts to the treatment too, right? I mean, it can, but can that vary on an individual basis or is cancer the same everywhere? What I'm I guess what I'm kind of groping at here is like, is it possible that I'm being treated for cancer and that the that my particular cancer and my particular you know bio ecosystem or whatever we're gonna call it here is is is is adapting to the treatment, and that may not be the case. Like my cancer cells may begin to adapt in a different way than some guy over there.

SPEAKER_00 54:09

100%. 100%.

SPEAKER_01 54:11

So I'm uh it really is fucking smart.

SPEAKER_00 54:14

Very smart. And so I am a leukemia doctor, and there is a diagnosis called CML, chronic um myelcytic leukemia, and we use pills for this treatment. And prior to these pills coming out more than 20 years ago, uh patients used to die from this disease. Now we give them pills. Some patients are on the same pill for 20 years, 30 years. They've been on the same pill, maybe not 30 years because we haven't been treated in that long, but more than 20 years. There are other patients who have been on their third pill, fourth pill, because they have developed a resistance mutation. And we are we our science has become so far, has gone so far where we can identify that particular mutation. And based on the mutation they've developed, we can now recommend a different pillar.

SPEAKER_01 55:03

Try to stay one step ahead of the cancer.

SPEAKER_00 55:05

Yeah. And so, yes, but some patients are still on the same treatment 20 years later. Other patients, after a year or two, have moved on to a different treatment.

SPEAKER_01 55:16

Okay, so in my perception, it seems like, you know, again, I don't know if it's true. But like everybody else, I'm obviously I get a lot of misinformation, but it seems like funding priorities sort of influence which cancers receive the most research attention. Are are certain cancers underfunded in your estimation?

SPEAKER_00 55:37

I think childhood cancers are underfunded. I think we know that breast cancers are overfunded. I think that the amount of research uh philanthropy uh that is done for those cancers, you know, the major cancers, lung cancer, breast cancer, colon cancer, probably receives a lot of funding. But, you know, you have to think about it.

SPEAKER_01 55:57

Yeah, I mean, like breast cancer has its own branding, even. I mean, I don't know another cancer that has a color that's kind of associated with it, or like, you know, the pink armband and yeah, yeah.

SPEAKER_00 56:06

And but unfortunately, there's cancers that are less common, like pancreatic cancer, esophageal cancer, uh, gastric cancer, some of the blood cancers out there, you know, there's just not as many cases of them, and so their funding is lower. So, you know, talking about them um are very important to raise awareness.

SPEAKER_01 56:26

Okay, well, I'm running out of time, but I I still got a ton of questions for you, but I'll narrow it down to just a couple more. Um, you know, uh if you if if you could uh solve one an unanswered question in cancer research right now, uh what would it be and why?

SPEAKER_00 56:46

I think one of the biggest concerns that I have moving forward in this space with so many new drugs and so many new options is sequencing. Um, you know, and I think that sometimes in drug development, many times in drug development, the goal is to get the approval from the FDA in a certain space. And once you have that approval, that's all they really wanted. And they're not going to be running these sequence trials unless it's gonna affect their market share. And so I think having oncologists understand um, you know, or just me trying to figure out how do I sequence these based on retrospective data, based on data that's not very robust, uh, is becoming a bigger issue. And I think it's something that we'll we'll be questioning for years to come.

SPEAKER_01 57:41

Well, thank you. I I think it's refreshing that you're willing to uh address it that way. Like, not, you know, like sort of admit that there is there is kind of a disconnect sometimes between funding and corporations and HMOs and like because that's where people's paranoia comes from. And if if the if the if the established medical community just denies, denies, denies, denies, that just makes the people that are misinformed more paranoid, paranoid, paranoid, paranoid. So like I think it's actually helpful for the cause to you to like openly say, yes, you know, there are problems and how these uh, you know, it's kind of like art and commerce. It's an awkward dance sometimes. Um so last question. Um this kind of harkens back to what I was talking about about manners. If I get cancer, I'd like you to be the guy that tells me how how how do you break the news to somebody? I mean, what have you learned is the best way to break that news?

SPEAKER_00 58:35

Yeah, and that's a great question. And I think it came after 10 years in practice. I think the main thing when I was early, but early on in my career, it was all about efficacy. It was all about this is the best drug. I was probably like a car salesman in some way, like this is the best option for you. Let's, you know, treat you with this. You know, now priorities have changed. You know, I listen to the patient, and there are patients that come and talk to me and tell me, I'm gonna do this first line treatment. If it doesn't work, I'd rather go and live on the beach in Florida for my last year than be here going to the lab and having treatment. So I think the main thing that I've learned over time is to listen. And that's the main thing I hear from patients who have misdiagnoses that uh that they weren't listened to or they didn't take, they didn't listen to their own body. They weren't their own advocate as well. I think listening on every level, I think is important. If you're an ER doctor and you've seen that this patient has come in multiple times over the course of the month, something else is going on. You know, maybe there's something occult that hasn't been diagnosed yet. If you're a patient that's not listening to those night sweats or rapid weight loss that you're having, you know, you need to listen to that and get to your doctor. Um, if you're the oncologist and the patient is telling you quality of life matters to me more than six months of treatment, you have to listen to that. So it's communication and listening on every aspect of healthcare, I think is important.

SPEAKER_01 1:00:03

And you know what? That's a beautiful place to end, because I would, I will one-up you there. I'll say listening is probably the single most important thing in every arena of our entire existence as human beings that we could all improve upon and and and and and learn to understand anything is listening. You know, I'm a big big mouth, you know, but I've actually I've actually got a lot better in adulthood at learning to listen. And I think I get, I I think I'm educated myself more clearly by listening than anything else. So um he is Dr. Emmett Garg. He is a good egg. Uh find him at Blood Doc Dad. Doc, thanks for being our fresh face in hell this week for for uh clearing up some of my misconceptions. And actually, I've like I walked away from this conversation actually feeling like I have a better understanding of how cancer works. So thank you for that.

SPEAKER_00 1:00:49

Thank you for having me. Appreciate it.

SPEAKER_01 1:00:53

A Fresh Face in Hell with Jonathan Evison is brought to you by Fresh Face Pods and produced by Jason Botkin and yours truly. Check us out on Instagram, YouTube, or at our website at FreshFacePods.tv. Don't forget to subscribe to our newsletter for updates and special content. And if you love the podcast, by all means run it and buy all of Jonathan Evison's award winning novels wherever books are sold.