“No Evidence of Disease,” or N.E.D, are the words that any cancer patient longs for once they've undergone their relevant cancer therapy. But then, what comes next?
Naturopathy and functional medicine have a lot to offer oncology patients, regardless of the phase of treatment they're in. Today we are joined by Tanya Wells, a naturopath whose expertise is in designing integrative oncology programs that utilise the best evidence-based complementary therapies to support conventional treatments. She discusses the full gamut of ways to support cancer patients once they have finished treatment, from how to provide continuity of care between visits with their oncologist and general practitioners, to the importance of psycholoical and emotional support, to preventing recurrence.
Covered in this episode
[01:05] Welcoming back Tanya Wells
[02:44] Steps to support patients post cancer treatment
[05:13] Anxiety over an uncertain future
[06:36] Psychological care post-treatment
[09:28] Lack of continuity of care
[11:13] What does “No Evidence of Disease” mean?
[13:39] Circulating tumour cells and other post-treatment testing
[16:22] Rethinking the phrases we use to discuss cancer
[21:11] Fear of recurrence and post-treatment anxiety
[25:56] Referring patients who need extra psychological or emotional support
[29:03] How relationships can change
[33:23] Detox after cancer treatment
[34:59] Common side effects of cancer treatment
[40:08] Reducing the risk of other cancers
[45:00] Managing menopausal symptoms
[47:11] Palmar-plantar erythrodysesthesia
[48:02] Tanya’s final thoughts on preventing recurrence
[49:34] Thanking Tanya and closing remarks
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us on the line today is Tanya Wells. She's a qualified naturopath practising for over 20 years. Her special interests and expertise is in research and development of integrative oncology programs, utilising the best evidence-based complementary therapies to work in conjunction with conventional therapies such as surgery, chemotherapy, and radiotherapy.
She's visited and worked in integrative oncology hospitals in Europe and Asia, and is continually collaborating with other practitioners to ensure her programs and clinic model are continually developing. Tanya is an experienced lecturer at the tertiary level, including at Southern School of Natural Therapies and Endeavour College, as well as at the Faculty of Medicine at Monash University.
Tanya has written and presented a range of drug-herb nutrient interactions, seminars for medical, pharmacy, and nursing professionals in integrative medicine, and she is a contributing author to a range of clinical textbooks. And I warmly welcome you back to FX Medicine, Tanya. How are you?
Tanya: Great. Thanks so much for that lovely introduction, Andrew.
Andrew: Well, it's not something you haven't earned. You've done a heck of a lot of work over your 20 years. Collaborative work, I might add.
Tanya: Yes, I find collaboration very enriching, especially with overseas practitioners who do things differently. And as much as we might not be able to do those things here, there are a lot of ideas and options for us to think about, just to broaden the way we think about oncology.
Andrew: Now today we're going to be talking about life after cancer treatment. Now, this is a whole can of worms, this one. So, what are the steps in supporting patients in the post-treatment phase?
Tanya: There are a number of steps. So just to give a little snapshot of where that patient is at, let's start with that. So, there are a lot of patients who choose not to have any integrative medicine during their treatment. They decide to just have the medical treatment, and then afterwards they might come to us for support in recovery.
But just to understand exactly what that person's been through is one of the biggest steps to start with as a practitioner. So that person has been, as far as they're aware, completely healthy, and then either because of a symptom, or a lump, or a random set of imaging, they've been given a diagnosis of cancer. Massive shock, and then immediately going into the treatment model.
Now, when you're actually in that treatment model, which might be surgery followed by chemo, followed by radiation, or just surgery, or just radiation, or chemo-radiation, or whatever the combination is, that happens very quickly after diagnosis and biopsy and imaging.
So that person has previously been on what we call the “oncology treadmill,” where you get on it and you can't get off, you know? You're on this process, just putting one foot in front of the other, getting through that, getting through all the appointments, getting through the day, managing everything else in your world, like kids and relationships and everything else.
And then at the end, that patient has been found to be N.E.D, which means “no evidence of disease.” They've finished their treatment, and they often feel quite literally abandoned by their medical team.
Andrew: Yeah.
Tanya: So their medical team will say, “Okay, you're doing great. Off you go. Come back in a year and we'll do another lot of imaging,” or “Come back in three months or six months. Get back to your life.” And that space is actually the hardest space for that person to navigate through the whole process because they are on their own.
Andrew: I often see this as having parallels to birth, and in that, there's a lot of prenatal care, perinatal care, and once you have a baby, it's like, “Bye.”
Tanya: Yeah. That’s right.
Andrew: And I know that's a joyous occasion, cancer is a horrible journey that people have to travel. But, as you say, it's where the anxiety and the fear, and the unknowing, uncertain future begin.
Tanya: And you're absolutely right, there are some parallels too, to giving birth because during the treatment process, all you can think about is “I've only got three cycles of chemo to go, I've only got two lots of radio to go, and then I'll be finished, then I'll be good,” you know? And when they're having a baby, it’s “Then I'll have the baby.”
But then - and you want that to be a joyous occasion - but the closer you get to the end of the treatment program, the more you actually start to feel stressed and depressed and anxious, because now you've got an opportunity to think “but, what's next? How do I...what has happened to me? What the hell has happened to me in the last year? How did I even get this? Why has this happened? Where do I go from here?” It's a very, very challenging and confronting space for patients to be able to navigate.
So in navigating that system and that space that they're in, there's a huge gap in our healthcare system. And this is actually where that person might seek out their complementary therapists to get some support.
Andrew: Let's say...let's take the example of breast cancer. Patients come out of surgery, chemo, radio, they've sometimes, or certainly in urban environments they've got breast cancer specialists, nurses for ongoing care. Now, it's very often wound and post-operative issues like cording and things like that. Is there any psychological care given to these patients?
Tanya: Look, it depends on who your treating team is. So if you've got a… and this is, unfortunately, where there can be quite a large disparity between the private and public systems.
If you're in a private system, often an oncologist will be able to say, “Right, off you go,” and if you actually pipe up and say, “I'm not coping," then they might say, “Oh, okay. Well, we'll refer you to a psychologist or the nurse practitioner, we'll refer you to a psychologist, and then you can go to your GP and you can get a mental health care plan, and get some subsidised consultations."
But even at the end, you're talking about having wound care and all that kind of thing, that's often finished. So the main hospital care has finished, and then you're progressing to physiotherapists off-site, who are then supporting you with the cording and any other sort of musculoskeletal issues associated with that. So that's away from the hospital system, and so you're not really in that space anymore, which you were receiving care from and then you're not receiving care from them anymore.
So you've got to actually drive the next phase on your own. You don't have someone else driving it for you. And this is also a moment where those patients actually have a moment to think, which we don't get to do when we're in treatment. And that is fraught with danger because you're sitting there, starting to think and reflect on your experiences, and it is very confronting to actually start to reflect on some of these trauma-based experiences.
Andrew: And I'm imagining that very little, if any, of this is discussed with the oncologist, or by the oncologist.
Tanya: Very little, typically. So, it does depend on the oncologist. Some oncologists are great, they will provide a lot of referrals, but they don't have the time or the space to really support that patient in a holistic way.
So this is where we come in, this is where referrals come in. But it's amazing how many people will come and see a naturopath or a natural health practitioner at the end of treatment, and when they haven't even seen a psychologist yet. So there's a lot of issues that we need to work through to be able to support that person. It's complex.
Andrew: Yeah. And yet, pragmatically speaking, oncologists drive cars, and oncologists would be filled with dread if they bought a car and there was no after-sales service, and continuing care of that car.
I find it strange that there's this real...a real disparity, a real sort of lack of continuation of care of patients when we know... I mean, we're talking about five-year, ten-year survival rates. Well, how about we work for that? How about we engage in the patient during that time to make sure that their time on Earth is as long as possible?
Tanya: Well, that's right. And this is where, often, the medical oncologists will refer the patient back to their GP for general care and recovery. The GP may do some follow up bloods, although that patient has had so many bloods done over the time that they've been receiving treatment that they often won't want any bloods.
Andrew: Right.
Tanya: And usually, if they really do have no evidence of disease at the time, the next lot of imaging won't be for a year, and then maybe some bloods at six months. So you will see a member of your surgical team or medical oncologist every six months, usually, so sometimes patients will stretch it out.
So they'll see their medical oncologist every six months, and they'll see their surgeon every six months. So they scatter them and stagger them so they see someone every three months, to have an opportunity to have a conversation about it. But in between there, there's an enormous three-month gap where there is a lack of provision of care.
Andrew: Right.
Tanya: And the amount of, the sort of care that you need during that time is very, very different.
Andrew: And I think we almost have to go back to what you said earlier, and that is “N.E.D”. What is no evidence of disease? What does that actually mean?
Tanya: So, this is the new phrase for...well, people used to say, “Oh, you're cured. You're in remission.” Those phrases aren't used anymore in oncology. Now it's just called N.E.D, so that's where there's “no evidence of disease” on any imaging, bloods seem to be clear, there's nothing that appears to be awry.
But they say this because, of course, there is no test that is completely accurate about detecting whether there are any cancer cells in your body. And you know, if you've done any oncology study before, you know that everybody is making cancer cells every day. We've all got dodgy cells in our system, and it's just whether they have an opportunity to replicate and become a population cluster or population.
Now, in order for something to develop its own blood supply, a little cluster of cancer cells, it needs to be one millimetre in diameter, and then its’ growth can explode to the point where it might be five millimetres or ten millimetres. Now, when it comes to imaging, a lesion needs to be around five millimetres to be detected on the average MRI or PET scan. So if you have a PET scan and there's nothing above five millimetres, then there's no evidence of disease.
Andrew: You've got a lag there, haven't you?
Tanya: So it's not necessarily the case that you have no cancer cells left. Remembering, too, that a cluster of cancer cells is what we call a heterogeneous population, so they're not all clones of each other, they have slightly different genetic makeups, slightly different growth tendencies.
So as much as that person might have had a range of chemotherapy drugs, there will still be those few cells that aren't killed, they're not killed by chemotherapy, they're not killed by radiation. There's a few cells that are surviving almost always. Which is why, with almost all types of cancer, there's a risk of recurrence, because those smaller populations of resistant cells can then become a new population as time goes on.
So N.E.D just means, look, with the current testing that we have at the moment, there's no evidence of disease present.
Andrew: So the simplistic thought after that would be “Well, why don't we measure circulating tumour cells?” But this, again, is fraught with issues, isn't it? Because as you say, we're making them all the time. When does it become a problem? When can we see issues?
Tanya: So, circulating tumour cell testing can be really helpful, and I certainly use that in my practice. I have found that circulating tumour cell test results are not necessarily reflective of a solid tumour presence. You can have very low circulating tumour cells but have a very actively growing tumour, and vice versa.
But circulating tumour cells are a good overall test. That is one test in the pack of tools that you will use in monitoring patients in an ongoing way. So yeah, there's usually a level of circulating tumour cells which is a cutoff point, you know? If it's above that, that's when we start to think about having interventions. If it's below that, then that's really kind of the normal range of circulating tumour cells.
Andrew: What about possibly measuring signals in the body, like their GEF?
Tanya: Yes, so that can be part of a circulating tumour cell testing package, where you can actually isolate circulating tumour cells and test their genetic makeup to see what percentage of those circulating tumour cells have mutations in certain markers of growth, or express that gene more profoundly than others.
And that can be a bit...that's also a very expensive package, so that's not necessarily realistic for the average patient, you know? I might see 5% of my patients will actually have spare money, especially after having cancer treatment, which can be very expensive, including lost income from not being able to work, and so on.
So there are patients who just can't afford that. So we have to go back to more basic options in general practice of naturopathy, and that's where we look at the other drivers or other factors that we can search for. So markers of inflammation, or looking at particular types of cancer and saying, “Look, methylation tends to be an issue in this type of cancer, let's test your methylation.” We can test other inflammatory markers, because that's a powerful driver of cancerous change.
Andrew: Right.
Tanya: Antioxidant levels, your basic nutrition status, and the status of your hormone system, which can actually be out of whack after having treatment.
Andrew: Right.
Tanya: So, all of those things we want to normalise before we get into complex testing.
Andrew: And what about the language that we use with our patients? We've discussed the psychological issues. There’s a colloquial term out there called “scanxiety,” what's the next scan going to show? That constant, brewing, hyper-vigilance that may not be occurring straight after, but certainly in the ensuing months and years after a cancer treatment, there is that risk of recurrence. And so how do we approach this properly with our patients without being...not pacifying, what's it called...placating?
Tanya: Hmm...that's a really good question. And there's sort of two parts to that question that I'd like to flesh out a bit. One is: what language do we use?
Andrew: Right.
Tanya: So, there are very common phrases that people say, you know? “Oh, you're on your cancer journey,” or “You're a cancer survivor,” you know? Some people wear that as a very proud badge of life, and other people don’t. They don't want to actually be reminded of that experience, especially if it's recent and they have very raw sensation about the trauma that they've been through.
The other thing is that often when someone passes away from cancer, we say, “They lost their battle with cancer.” Now, that phrase is actually profoundly unhelpful to patients who have cancer, because if you think about it, you go into a battle, you can see your opponent. You can see what weapons they have. You can see how big they are, and what your chances of defeating them are.
But cancer, of course, is an invisible foe, an invisible weapon. We have no idea what to do to defend ourselves against those processes. So that kind of phrase… We have to just rethink the way we say things, because that kind of phrase almost implies fault on the part of the patient. Oh, well, you didn't fight hard enough, you know? That kind of thing.
Andrew: Oh, I see. Right.
Tanya: So we have to just to be a little bit more mindful about the language that we use, and even the phrase "risk of recurrence,” you know? I've found that in clinic, I have to say that phrase less and less because that risk of recurrence is a reminder that you actually might have a recurrence.
And throughout their process, they will be hit with a number of statistics by all of their practitioners about what their risk of recurrence is, over and over and over again. “Oh, yeah, that's a five-year survival rate, your five-year survival rate is likely to be this with treatment, or this without treatment.”
So, patients have a very sensitised reaction to language. So let's talk about things like “Let's promote healthy longevity,” rather than “Let's reduce your risk of recurrence.” So I often talk about healthy longevity, we're talking about living in the moment, embracing life. We're trying to speak in a more positive way, just to try to be deferent to the language that they tend to be faced with in the medical system.
Andrew: And what about things like, “Don't worry, now you're over the hump. Everything's going to be okay now,” that sort of thing?
Tanya: Yes. Of course, as humans, we want to support people. We want to be supportive, and it's our natural status to give platitudes like that. Unfortunately, if you have a good conversation with a psycho-oncology professional, we know that platitudes are kind of fundamentally unhelpful because if we say something like, “Don't worry, it's going to be okay,” that person, there's that little voice in their head that says, “Well, how do you know that it's going to be okay?”
Andrew: Yeah.
Tanya: I've been told this statistic, I don't really know what we're trying to do. And this is where we refer to psychologists to have that support, is to help that person to live with uncertainty. How do you live with uncertainty?
And part of that is living in the now, bringing that person back to now. I have some patients who are so overwhelmed with their fear of recurrence that they are quite literally unable to function in the world. They are unable to have relationships with even their family members, husband, wife, because they're so crippled by that fear of recurrence and statistics.
So it's more about saying, “Look, now you don't have a recurrence. Now you are healthy, and I'm going to support you to have even greater promotion of healthy longevity. Let's focus on that, let's live in the now.”
Andrew: During this time of hyper-vigilance, particularly straight after their original treatment, is there a period at greater risk for them? And is this driven, indeed, by their anxiety hormones?
Tanya: Yes. In most cancer presentations, the greatest risk of recurrence is, of course, in the first two to three years after having a diagnosis, because that's where you might have those residual resistant cells present, that haven't been eliminated by the treatments that you've received.
In those first two to three years is where that patient will understandably be hyper-vigilant, understandably have that level of scanxiety that you talked about before, and be excessively focusing on every little thing, you know?
They'll say, “Oh, I've got a little wound on my hand, is that cancer?” Or “I've got a cough, have I got secondaries in my lung?” “I've got one little thing.” Of course, the first thing you think about is cancer. And then, of course, when you go on Dr Google, if anyone's Dr Googled a cough...
Andrew: Cough, yeah.
Tanya: ...one of the first five things that comes up, of course, is cancer. So we are understandably traumatised during that time, and this trauma is actually one of the biggest issues in that… We sometimes talk about it as being a post-traumatic syndrome. It is like that, but you know, patients aren't necessarily anxious about what might happen, it triggers an anxiety about what did happen. What did happen the last time they had a scan. What did happen to their body, what did happen to their energy, and you know, they may have had profound vomiting, or whatever happened in their cancer experience.
So, this is where the hyper-vigilance, it's validating that fear without necessarily allowing it to continue. I've got an example just from today. So today, in clinic, I saw a patient who has been my patient, she's been N.E.D for the last three years, original diagnosis bowel cancer, with mets (metastases) in the lung, and she is presenting with a cough now.
This is something that we have to be vigilant about. We have to look at this and say, “Okay, tell me about the cough.” It seemed infectious, started with a fever, but it has lingered beyond the time at which it would be imaginable that she would recover from that now.
Andrew: Right.
Tanya: So this is one of those periods in which we have to say, “Right, when's the time for us to refer this person back to their oncology team?” From my perspective, it's not that time yet because her cough is actually improving with naturopathic treatment. So if she had an oncology-related cough because she had a new metastasis in her lung, that cough would not be improving with a herbal mix, and with some nutritional supplements. That would be staying the same.
Andrew: Right.
Tanya: So with her, she's very fearful that it's a recurrence. So we have to look at it very clinically and say, “Okay, there is the possibility that's a recurrence, but let's see what the criteria would be. I'm not ready to refer you back to your medical oncology team yet because your cough is improving with treatment, and that doesn't match the clinical picture of someone who's having a recurrence.” So, that's supporting alleviation of that patient's fear with logic rather than just a placation.
Andrew: Yeah. And so after a reasonable period of time of treatment, you withdraw that treatment. If that cough returns, then you would say, “Okay, look, maybe there might be an issue here that's ongoing.” Is that right?
Tanya: Yes, yes, yes. And that period of time does vary according to who you speak to. There's a great surgeon in Melbourne called Bruce Mann, he has got a two to four-week rule. So if you have a non-improving symptom for two to four weeks, then you go and get some imaging done, or some testing done.
Andrew: Yes.
Tanya: But if it's less than that period of time, then don't worry about it. And other practitioners might say three months. I think three months is a bit long, but I would say two to four weeks of a symptom not improving, that's when you would go and get some further tests about cancer markers, or some imaging to confirm whether everything's okay.
Andrew: When you're talking encouraging words, and you're sort of flipping them and having a positive outcome, so we've got to concentrate on longevity and things like that, that's all well and good for the clinic environment when they feel safe. They feel heard. They're with somebody who's expert, like yourself.
Then they go out and they talk to their friend. Or then they drive somewhere and their inner voice starts talking. How do you keep patients on the positive track? Because we know that chronic, like noradrenaline, chronic stress hormones are drivers of tumours, and certainly recurrence. So, how do we keep people from exacerbating the issue?
Tanya: Hmm. That's something that we have to have a team that we refer to. So for me, I'm going to be encouraging them to start developing habits like mindfulness, allowing themselves to feel that fear, allowing themselves to explore it. I'm very big on having a safe space to actually feel what you need to feel without going, “oh, no, I'm not going to feel that, I'm going to get going, I'm going to move on, I'm going to soldier on,” you know? Just allow yourself, and be compassionate.
Self-compassion is something that I'm very encouraging of, but also referring to appropriate practitioners. So I'm not a psychologist, I don't have the skills in being able to give these strategies to help with those complex issues. I've got the basics of knowledge about psychology, and certainly being in oncology for 20 years you develop certain skills. But beyond that, I always refer to a psychologist or a counselling team for regular support.
And after treatment is where a patient wants that support, they have the time and space, or the headspace to actually start to explore the shock of what has just happened, and other anxiety, depression. Your life, and you as a person have evolved irreversibly. You have evolved into a new person through this experience. You actually can't go back to your life like the doctor says.
Andrew: No, no.
Tanya: You have to adapt to a new normal, and all of your relationships change. You know, you get annoyed with people, people will complain about, you know, something pathetic, and you get angry because you've had to deal with something extremely stressful. And so that, in comparison, just seems like it's not even worth vocalising.
Andrew: This is kvetching, right? You know about that?
Tanya: Yes. We've got to... Yes. So we've got to support patients, but also know our limitations, know your scope of practice. And this is where we are trying to support them in that moment, to be able to refer them on to appropriate practitioners to help guide them through being mindful, doing mindful courses. There's plenty of mindfulness training courses out there that are incredibly supportive in the post-treatment space.
Andrew: So is it a case that... As you say, these people have evolved, and they may actually have to change the sphere of people with whom they interact.
Tanya: Yes, that does happen. And certainly getting annoyed by other people kvetching is usually a transient issue. So that's something that happens quite close to finishing treatment, where it's all very raw. You're still feeling like crap after your treatment, you've got to try to get back to work, so you're very sensitive to things. But...
Andrew: Your hair is growing back. Yeah, it's curly...
Tanya: Yes...yes, you still look like you have been through cancer treatment. But this does settle, but yes, you're right, relationships can change. And this is something that we need to be supportive to those patients.
Another patient example that I've got from yesterday, a patient has just finished all of her breast cancer treatment. Now, she had a mastectomy with reconstruction from the abdomen. She then had...well, she had chemotherapy first, three different chemotherapy agents over six months, then surgery, then radiation. And now she's at the end of this, on an aromatase inhibitor, so ER-positive breast cancer.
Andrew: Yes.
Tanya: So she's just finished a month ago her radiation, and throughout her treatment her husband did not touch her once. So, he could not be intimate with her.
Andrew: Right.
Tanya: He just couldn't touch her, and she would talk about that a lot during treatment. It was very distressing for her. And it's only...and we talked about it at the time, and as much as it's something that is very difficult to experience from someone you love, that they're not touching you anymore and that intimacy is lost, which is actually a very common scenario.
You get to the end, and this is where there's an opportunity to talk about these things. And this lady's husband came into the consultation, and we actually just opened it up and talked about that. Now, you don't have to be a psychologist to do that, but it's more about...you know, he wasn't sure where to touch her, and she was so distressed all the time, how can I touch you?
But in the end, really, it's just any touch is good, because all she's getting is clinical touch during the treatment, and what you need is just a hand on the arm, you know? It doesn't have to be full intimacy, it's just loving touch. But you know, he started to express how he felt about it, that he just didn't know how to touch her. Her body has changed, his image of her has changed. That whole relationship has changed. She's got...you know, she had a revision of the other breast, so she's got a new body. She’s got scars, she's distressed, she doesn't look the same as she did before or behave the same way. There's a different person in front of you, and it's hard to connect on that intimate level.
So you know, there are so many complex issues in this space that in recovery, that's the time that we can actually start to explore these things, and also refer to other practitioners, like a psychologist. But that talk there wasn't about psychology strategies, it was about, “Well, let's manage our expectations of ourselves and others.” And that's something that we have to start to do, as well as a newly recovering patient, is just work out what we can and can't expect from people.
We can't expect them to understand what we've been through. We can't expect them to say the right thing. We don't know how to react in this situation, we've never been there before. We wouldn't have a clue how that patient is thinking and feeling, so most people just do their best. But because they're so sensitive straight after treatment, it's a very stressful time.
Andrew: Yeah. And of course, that can put their significant others in on, you know, sort of walking on eggshells around them as well. So I totally get that point, yeah.
Tanya: Yeah. So I mean, it's understandable that she wanted more intimacy, but it's also understandable that he was having trouble...for any man it would...
Andrew: Yeah, worrying about when it was appropriate.
Tanya: Yeah, he was constantly worried. That's right.
Andrew: So the role of the practitioner, like, for instance, we've come out of chemo/radio, we want to get the body back onto a path where a smouldering inflammation is not brewing, if you like. So, let's go simple things. What about detox after cancer treatment?
Tanya: Absolutely. So, this is where we have to go back to naturopathy 101, and you don't have to be an oncology specialist to do this. It's about what are the biggest issues in cancer treatment? Detoxification. Your detoxification organs have been put through the wringer, being exposed to profound toxins. And if that person has received radiotherapy, that radiotherapy continues to have an effect in their body for one year, at least.
So it means that detoxification needs assistance for one year at least after treatment. So yes, liver support, gut support. Remember that chemotherapy, the purpose of chemotherapy is to damage cells that are growing rapidly, and the cells that grow most rapidly are in the gut, that mucous membrane in the gut.
So absolutely, go back to your basics of naturopathy 101, focus on basic fundamental gut health, regenerating and rebuilding that gut lining, the microbiome, prebiotics, probiotics...eventually. Don't give them probiotics straightaway. But we're building that integrity of the gut, supporting liver and kidney function, and that's definitely the foundation of the treatment that they need to receive after they've finished cancer treatment.
Andrew: Right. And what about side effects? We all think about the side effects of cancer therapy, let's say chemo or radio, the common ones, the fatigue, that sort of thing, the nausea and vomiting. But what about where other organs are affected by, say, radiotherapy? Breast cancer, for instance, goes right near your heart, right through your lungs.
Tanya: That’s right
Andrew: You know, there's renal disease that can happen from long-term dox. So when we've got these other tissues involved, that may not have been the original problem but are sort of innocent bystanders. How do we manage that? How do we make sure that we're looking after them?
Tanya: That's right. And there are a lot of issues, so we'll go through a few of the most common. So, probably the most common residual symptom after cancer treatment is fatigue. But we do need to just determine what that fatigue is coming from.
So for example, you’re right, with radiation to the chest, or some chemotherapy agents in the antibiotic family, like doxorubicin, they affect heart muscle function. And certainly the effects of radiotherapy on the heart are better with the new radiotherapy techniques, like the deep inhalation and breath-hold. But still, it might be cardiac-induced fatigue. So if they do actually have an echocardiogram you can have a look at, you can see what their ejection fraction is. If that's low, then they need cardiac support.
The other area to consider is, of course, bone marrow function. So of course, bone marrow is also one of the most rapidly dividing cell sites in the body, and that's affected by all chemotherapy and radiotherapy. So, supporting bone marrow function, we've got multiple mushroom complexes and other arabinoglycans and other substances that can support bone marrow function, and we want to incorporate those.
Andrew: Yes.
Tanya: Or it might be adrenal, you know? They've had to pace themselves through a year of treatment, and adrenally, they needjust a good naturopathic tonic, some sleep, they need support. And they may actually have sleep issues from their treatment, especially if they have night sweats, or they've got chemotherapy-induced menopause, as women. Huge issue.
So, sleep and adrenal function can affect fatigue, cardiac issues, as you just said. So we're looking out for things like shortness of breath, arrhythmias. Long-term peripheral neuropathy can occur even just with one course of the drug Paclitaxel, or it can also be from long-term platinum agents and so on, other chemotherapy agents.
So, peripheral neuropathy is damage to the nerves at the periphery of the body, so the hands, the feet. It can also be in the face or in the mouth, the tongue, where you get altered sensation. Now, that's actually secondary to capillary damage. So those baby capillaries get damaged, they then basically die off, and the nerves can get damaged. So we're wanting to support cardiovascular and nerve function, and we want to make sure that we're giving that treatment, especially if that symptom is slightly there, we don't want it to become a permanent issue.
Pulmonary fibrosis is another one that's quite common with radiation. So, pulmonary fibrosis is where we can have scarring up of the lung as a consequence of radiation to the chest, and there are some vitamins that can be helpful for that, specifically vitamin E. But you need to take that for a good year after having radiotherapy.
Andrew: Do you prefer any particular forms of vitamin E, like the new tocotrienol mixes?
Tanya: Yes, I have used those tocotrienol mixes. I'm a bit of a mixed tocopherol practitioner, mostly because that's where the majority of the research indicates that the vitamin E is helpful. But I do still use a mixed tocopherol blend as my baseline treatment.
Andrew: Yes.
Tanya: I guess a couple of other worthy mentions, with regards to side effects, is osteoporosis and fracture risk, and fertility issues. So, more and more patients are being diagnosed with cancer quite young, and this is where we're going to be supporting their return to fertility, as well as their return to vitality after treatment.
And this is another area that is becoming bigger and bigger and bigger, you know? I'm constantly referring to fertility specialists, naturopaths to be able to get that person up to that level of vitality where they can bear a pregnancy. Or if it's a man and they've had testicular issues, being able to have good fertile sperm concentrations in their ejaculate. So, we really want to support that return to fertility.
But I guess, really, the last big issue to discuss, with regards to side effects of treatment, is the risk of other cancers.
Andrew: Yeah.
Tanya: So, there is a risk of secondary cancers because of treatment. And certainly with chemotherapy, there is a risk of haematological cancers.
Andrew: Right.
Tanya: There's also risk of secondary cancers from radiotherapy. Radiotherapy damages all of the cells, healthy and cancer cells, it's just that the cancer cells don't have as good repair mechanisms as the healthy cells. So you're still getting damage to the healthy cells with repeated fractions of radiotherapy. And of course, that can lead to dodgy cells, which in the future may become cancerous.
So, if we know some details about their radiotherapy treatment, then we can start to learn about the possible risks, and then tailor our anti-inflammatory and antioxidant protocol to support reducing that risk of secondary cancers.
Andrew: Right. And is this where you also employ surveillance, sort of looking at markers, tumour markers as well?
Tanya: Yes, if they do have a cancer where you can look at a tumour marker, then that's great. If they don't have any sort of tumour marker options, we usually look at general bloods, inflammatory markers, and make sure all of their baseline foundational vitamin levels, which have an impact on the antioxidant processes, like vitamin E, vitamin D levels. We want those D levels to be up above 100. We might look for oestrogen metabolite testing to see how their body is detoxifying, if they have a hormone receptive cancer, we want to look at liver function markers and inflammatory markers. Again, often going back to those basics of what sort of tests can you do to determine whether that person is in a state of vitality.
Andrew: So, a few other things that we could use to combat these issues. Like fatigue, for instance, I remember a paper presented to ASCO, a massive clinical oncology conference over in America. And it spoke about American ginseng.
But the issue was that it was not successful over, I think, one month, it was only successful over two months. So you had to sort of basically get the patient on board. There was a decent dose there, I think two grams, as well. It was notably without side effects.
So, what sort of other things do you employ here, apart from, of course, the basic things like exercise?
Tanya: Yes, exercise definitely does form the basis of treatment. I mean, if you look at the research about exercise, for example in breast cancer, if you have been diagnosed with breast cancer, and you have never exercised in your life, if you start exercise after your treatment is completed, it can reduce your risk of recurrence by 50%, which is more than anything else combined.
Andrew: Huge, yeah.
Tanya: It's huge. So a referral to an exercise physiologist, especially if there are any ongoing musculoskeletal or cording or fatigue issues. And you're going to get muscle wastage through that time, so exercise physiology referral is enough. And just encouraging people to just be active every day. It doesn't have to be going to the gym and doing a CrossFit session, it can just be being active with their dog or kids or whatever.
But I do have a few favourite things that I use in this stage. Mostly it'll be very naturopathic restoratives, so yeah, adrenal blends with withania, astragalus… Astragalus is still one of the most useful...
Andrew: The mainstay.
Tanya: ...cardiotonic, bone marrow tonic...there's plenty of evidence to support its use in this space. Mushroom complexes, basic vitamins like E, A, depending on the type of cancer. B-complex and phase two detox support in liver detoxification. And just bowel reboot, gut reboots, complexes that have not so much glutamine, but all sorts of other nutrients for digestive regeneration, and eventually some probiotics and prebiotics thrown in there.
But I do tend to use a lot of antioxidants and anti-inflammatories, so we might use things like curcurmin, green tea extract, a lot of mixed tocopherols to support patients in this phase.
Andrew: What about things like the ongoing issues of menopause, treatment-induced menopause and drug-induced menopause, because they're now on an aromatase inhibitor. How do you effectively look after these dreaded menopausal symptoms, the sweats… What can we use?
Tanya: All the same things we would use if they weren't a cancer survivor, okay? So we're going to be using a whole lot of herbs like sage, and... not all of the herbs that have an oestrogenic base, by the way. We often have to be quite careful.
Certainly you're giving patients vitamins. Vitamin E, I've found to be particularly good for treatment-induced night sweats and hot flushes. We've also got exercise can reduce hot flush incidence and severity by about 30% to 50%.
Andrew: Right.
Tanya: Which is an ironic...you know, you want them to sweat, and yet it helps reduce their sweating.
Andrew: Yeah, so any particular exercise here?
Tanya: That is actually cardio exercise.
Andrew: Right.
Tanya: So, a little bit of cardio exercise. Although just be aware with cardio exercise, we don't want them to exclusively do cardio because doing cardio exercise every day does lead to a cumulative buildup in cortisol levels.
So cortisol, as a stress hormone, can actually worsen hot flushes. And this is another thing about hot flushes, you can also get hot flushes because of adrenal issues...
Andrew: Of course. Yeah.
Tanya: ...not just menopausal issues. So we're trying to… or thyroid issues. And that's why I mentioned before about hormonal imbalance, just checking their baseline endocrine feedback loops because patients can have disordered thyroid function after treatment. Or they may have disordered adrenal function after treatment.
So I often do it a urine analysis or a urine metabolite test, where I'm looking at their cortisol levels throughout the day, and cortisone levels, just to check on their metabolism, just to see, you know? The hot flush isn't necessarily just because of the aromatase inhibitor, it might be because they've just endured a year of treatment and they're adrenally exhausted.
Andrew: Right. So, things like pain... Oh, I know, hand-foot syndrome, palmar-plantar erythrodysesthesia. I got it out.
Tanya: Yes...well done.
Andrew: So PPE, what sort of things do you use for that?
Tanya: Well, I do use, like, the B vitamins, methylated B complex I would use, but also vitamin E, and PEA. So I use quite a lot of PEA these days, and that is also very effective for peripheral neuropathy symptoms. But I don't find people that have extended hand-foot syndrome all that much after treatment has finished. That's a very common symptom during the treatment...
Andrew: During treatment, yeah.
Tanya: ...during treatment, but not so much after.
Andrew: There's so much to cover and to know, Tanya. I've got to say, thanks so much for taking us through all of this.
Is there anything else that we need to know, or any relevant resources that we can go to to learn more?
Tanya: I guess it's one of those things that we're doing patient-by-patient. So you know, when you've got someone who presents with a type of cancer, and they currently N.E.D but you're wanting to try to reduce risk of recurrence, I guess we need to just look up that type of cancer in the medical research, see what the drivers of that recurrence are.
So, the main driver might be an inflammatory process, or the main driver might be an antioxidant process, a pro-oxidant process. So this is where we do want to find out about each of those cancers, and just try to inhibit those processes as much as possible.
I guess the two areas that I focus on the most in that prevention of recurrence space is inflammatory processes, and also just promoting antioxidant pathways, especially with liver detoxification, glutathionylation, and so on. So all those phase two detoxification pathways and antioxidant pathways, as well as managing inflammatory load.
They'd be the two areas that really, as a fundamental prevention package, we would want to focus on those. But then don't forget the person that's sitting in front of you. They just might need a good adrenal tonic, a nice sleep mix, and a herbal hug at the time.
Andrew: A herbal hug, I love those words. Tanya Wells, there's a wealth of experience between those ears of yours, thank you so much for sharing some of it today on FX Medicine.
This is obviously such an in-depth issue, I'd love if you would join us back on FX Medicine at another stage, to go through other issues in caring for cancer patients both during and after treatment.
Tanya: My absolute pleasure, and yes, I'd love to. Thank you so much, Andrew.
Andrew: Cool. It'd be great. I look forward to it. This is FX Medicine, I'm Andrew Whitfield-Cook.
Other podcasts with Tanya include
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