nicely just watch it online so thanks for coming everybody i appreciate it it's nice to see everyone and so today we're going to basically give a talk called optimizing your ability to fight cancer so this is part of the if you were my family member series and really it's predicate on the notion that i'm probably one of the only people in the world who knew that he wanted to be a cancer doctor when he was four years old so my dad he was a cancer researcher and he used to take me to his lab at the veterans administration in minneapolis when i was young and so the first time i ever saw a cancer cell the first time i knew i wanted to be a cancer doctor i was four years old so for the last 42 years i'm 46 now i've thought about cancer almost every single day and that's not an exaggeration i've thought about cancer almost every day since i was four years old and i always tell people you can think about cancer every single day and you can see it monday through friday eight to ten hours a day you can see it on weekends it doesn't matter because until you actually have cancer you have no idea what it's like to have cancer so when i was making this series i really thought about what i would want people to know if they were my mom dad brother sister child and that's the fundamental metric for me right that's how i look at patients if they're not getting the care i would expect for my mom dad brother child brother sister child then something is wrong and i have to fix it so when i was making this particular series i thought about okay what would i want patients to know if i was in the room with them and they were my family member and that's how this particular series was born in this particular talk in particular so when i was thinking about this talk right this seminal talk for this particular series that's supposed to apply to all patients with cancer what i realized is that this talk is almost impossible to make because how do you make a talk that's universally applicable when the population you're talking to is incredibly heterogeneous you know no two cancer patients are the same period when you've met one patient with cancer you've met one patient with cancer so when i came up with this talk i thought okay probably the best way to do it is to give people 10 survival tips ways to optimize their ability to fight cancer that are relatively universally applicable survival tip number one the anxious matter i don't know what to say really three minutes to the biggest battle of our professional lives all comes down to today we heal as a team we're going to crumble inch by inch play by play till we're finished we're in hell right now gentlemen believe me and we can stay here get the [ __ ] kicked out of us or we can fight our way back into the light we can climb out of hell one inch at a time now i can't do it for you i'm too old i look around i see these young faces and i think i mean i made every wrong choice a middle-aged man can make [Music] i uh i pissed away all my money believe it or not i chased off anyone who's ever loved me [Music] and lately i can't even stand the face i see in america [Music] you know when you get old in life things get taken from i mean that's that's that's part of life but you only learn that when you start losing stuff [Music] you'll find out life's just gaming inches so is football because in either game life or football the margin for error is so small i mean one half a step too late or too early and you don't quite make it one half second too slow too fast you don't quite catch it the inches we need are everywhere around us they're in every break of the game every minute every second on this team we fight for that itch on this team we tear ourselves and everyone else around us to pieces for that itch with our h because we know when we add up all those inches that's gonna make the [ __ ] difference between winning and losing i'll tell you this in any fight it's the guy who's willing to die who's gonna win that itch and i know if i'm gonna have any life anymore is because i'm still willing to fight and die for that itch so in cancer care the inches are literally everywhere if you have a patient who has a fever in the context of getting chemotherapy where their immune system is sufficiently suppressed we know that if you delay treatment antibiotics for even an hour mortality goes straight up patients dot if i correct someone's sodium when it's sufficiently low too fast i can make them quadriplegic if i correct their high blood pressure too quickly i can cause a stroke so in medicine and cancer cure the inches are everywhere and it's a patient's responsibility to understand what those inches or they entail quite a bit and a lot of different symptoms but fevers headaches that are new onset or wake you up from sleep neurologic deficits where you can't move an extremity or you have issues with your vision that's new back pain that's new shortness of breath that's new profound diarrhea these are all inches and you need to let us know about every single inch because if you don't tell us about the symptom and we lose that inch that can certainly constitute the difference between living and dying so survival tip number one is that the inches matter and you have to be hyper vigilant not just vigilant you have to be hyper vigilant and i always tell my patients you can never call me too much but you can call me too little when you talk about cancer what you're talking about is something that's inherently heterogeneous there are very few universalities in the world of cancer but there is one i can think about and one that i actually think is probably true the sooner the better the sooner we catch your cancer the more likely you're going to do well the sooner i know about a symptom the better you're going to do so survival tip number one is the inches matter survival tip number two know your opponent i wrote this article for biofitron.com where i have an editorial series it's called quarterbacking the patient's cancer care and in that article i equate being an oncologist to being the quarterback of a football team where the owner is the patient where you're trying to win on your patients behalf and what i do as a quarterback is i walk up to the line of scrimmage where i my teammates nurses pharmacists all of the different pharmaceutical individuals that are involved in helping bring drugs to market the custodial staff the clerical staff everyone on my team the first thing i do when i get to the line of scrimmage is i look at the defense and i survey the opponent i study the patient's cancer because everything i'm about to do has to do with my assessment of that cancer and as a patient as a physician we both need to know the opponent and what's fundamentally important is that the opponent's never the same your opponent is always different than some other patient's opponent no two cancers are the same they have different protein expression profiles different histology they have different molecular profiles different stages and amounts of cancer different locations of disease and different patterns of growth and response the biology of the cancer is different whenever i see a patient with cancer it's to me basically like being in a vacuum no other patients on my mind no other patient is the same if you look at these two patients they're both patients of mine consider this patient on the left they have a triple negative stage four breast cancer you can see a couple spots here in the liver and a spas lymph node here in the mediastinum consider this patient on the right they have disease up and down the spine up and down the skeleton you can see it in numerous ribs you can see it in the left femur you can see it in the right femur now if you looked at these pictures you would think objectively this patient over here has a much worse prognosis and is in a much worse situation but that's not true because the protein expression profile tells the story here this patient on the left has a triple negative breast cancer meaning they do not make any of the three proteins that we look for the actual receptor progess receptor and her2 so they have a triple negative breast cancer which are infamously difficult to treat this patient on the right makes the astro receptor and the progesterone receptor but they do not make her two they are hormone receptor positive and her2 negative because of that fact because of that very simple fact the patient on the right is likely to have a very decent outcome whereas the patient on the left is going to be a struggle it's going to be a fight it's not going to be easy not only does protein expression profile tell a story but the histology of your cancer tells a story as well so histology is the study of microscopic structure of tissues and what's critically important about histology is it basically tells me as a physician what i'm treating right so pathologists who basically look at the histology of a cancer and tell you exactly what that is what story that's telling are incredibly important we are entirely reliant on our pathologist and the idea is that the histology will tell you the cancer subtype it will tell you the cancer of grade so let's talk about subtype for a second when we talk about lung cancer right cancer just a cell that grows an uncontrolled way breast cancer breast cell lung cancer lung cell when i talk to patients about lung cancer i write on a white board for every single patient i meet i literally give them a talk on their cancer when i'm talking about lung kids the very first thing i tell them is lung cancer is a lung cell that grows an uncontrolled way but there's two big types of lung cancer there's small cell lung cancer and non-small cell lung cancer and in the non-small cell group there's different subtypes there's adenocarcinoma squamous cell carcinoma large cell carcinoma sarcoma etc etc and the subtype matters the type of cancer matters the type of lung cancer matters we treat it differently it has a different prognosis we anticipate different things based on the subtype which the histology tells you in addition we also look at grade so grade gets a little complicated but the way to think about grade is basically how aggressive does a cancer look when you're looking at it under a microscope does it look really aggressive are there features that are problematic or does it look fairly timid now typically we grade cancers one through three or one through four the higher number means it looks most aggressive i want you to ask your physician what the subtype of your cancer is and what the grade is it impacts treatment it can impact prognosis so absolutely absolutely i want you to understand the histology of your cancer next something that is actually really important something i talked about in 2015 when i gave this talk but i'm going to emphasize tremendously to that is you have to understand your cancer's molecular profile so when we talk about molecular profile basically what we're referring to is the genetic and protein composition of your cancer now the reason it's important is because it can help guide your treatment and it is particularly important for cancers that are theoretically incurable in fact if you have a theoretically incurable cancer so stage four breast stage four lung a lot of stage four colorectal stage four liver the first thing i want you to ask your position when they say you have a stage 4 cancer that's incurable is what is my molecular profile or are you sending it you need to know what the molecular profile is now i don't want to get into the weeds here i actually gave a separate talk that you can see on the revolution cancer channel a couple weeks ago on this particular subject i'm actually going to do this again for patients in the future to make it a little bit easier but all i want you to do is look at what i have in green here write it down and take it to your doctor i want you to ask them about something called next generation sequencing ngs basically what this refers to is the fact that we are taking your cancer cells or the dna in your cancer cells or yeah dna in your cancer cells or dna that's free in the blood from your cancer cells and we are looking to see if there are certain genes that are mutated and the idea is pretty simple if you have a mutation let's say in a purple gene then we have a drug a purple drug that corresponds that mutation that we can use to treat it incredibly effectively in addition if you have a mutation in a green gene we have a green drug orange gene orange drug and so the idea here behind the extension sequence is we are looking for mutations in your cancer that we can take advantage of a weakness in your cancer that we can use to attack it additionally aside from next-generation sequencing we also do pdl-1 tmb testing and msi testing on your cancer now the idea behind pdl-1 is that cancer cells oftentimes will make a protein called pdl1 which will basically shut off your immune system cell so your immune system does not attack your cancer and so what i want you to ask your physician is how many of the cancer cells in your body make pdl1 this protein and the reason i want you to know that is because the higher the level typically the better response you'll have to immunotherapy so immunotherapy is really simple it's just treatment we give you to rev up your immune system to recognize your cancer as foreign and attack it so the higher pdl one that you have the more likely you are to respond to immunotherapy similarly if you have a high tumor mutation burden you're oftentimes likely to respond to amino there because the tumor mutation burden it's exactly like it sounds when you look at the cancer cell's dna how many mutations does it have in it the higher the number of mutations if your tmb high classically you will have a much more likely chance of responding to immune therapy the last thing i want you to know in this context is something called microcellular instability so microstability sound basically refers to how unstable is the dna in the cancer cell and what we know there is that the higher the level of dna instability the more likely you are to respond to immunotherapy this is actually critically important so all told when we talk about molecular profiling i want you to ask about next ration sequencing pdl1 tmb and msi the last thing i want you to ask for and this gets a little complicated is something called homologous recombination deficiency now homologous recombination deficiency is one of the ways cancer cells and normal cells repair dna that might be mutated and what we know yeah yeah and then i found out why it's cleaning you're saying in their ability to basically do homologs for combination then they're more likely to respond to carb inhibitors so poly ribose polymerase inhibitors like elaprib naraparib valiprib taylozoperib rucoperib these are all drugs that are part inhibitors that we can use in patients who have homologs for combination deficiency in their cancer cells so what i want you to do is i want you to write these five things down stuff in green okay particularly if you have an incurable tumor ngs tmb msi pdo1 hrd go to the doctor and you say did you obtain this and what were the results now i'm giving you some examples of specific genes and specific molecular abnormalities that we look for in cancer you can see it depends on the stage depends on the tumor type i don't want you to have to memorize this and in fact i could have done this for every single cancer out there including hematological diseases this is something i do i think relatively well i didn't want to focus on this someday i will i will do an entire talk on this for you you can look at this slide if you want the reference but the idea is the molecular abnormalities that characterize various tumors with various stages are different they differ with respect to the cancer type they differ with respect to stage in terms of what we look for but this is what i want you to see this is something most people don't show you so this is a patient with stage four non-small cell lung adenocarcinoma with an egfr exon 19 mutation this patient because of that mutation that egfr mutation was given osimeritive now look at this patient when they first presented they had numerous lesions in the brain numerous cancers in the brain in 13 days because of the mutation in egfr they got after getting ulcermarine you can see in 13 days on almost america there's no disease in the brain that's visible by mri but that's not just it take these two patients who both have stage four melanoma with a b raft b600e mutation so we look for a mutation in a gene called b raf it's a specific mutation so it's b wrap b600e which is present about 40 of patients with stage 4 melanoma and what we do when we see it is we give patients drugs to drug combinations that basically target that mutation now what you see on the left in patient one right here you see a patient who presented to their physician with an unbelievable amount of disease look at this picture you can see they had disease that infiltrated the entire liver all that you're seeing here this is all cancer cancer in the bones cancer in the liver cancer up and down the spine because they had that b wrap b600e mutation they were eligible for a drug called venmarafin if this was about 10 years ago this patient got memorable two weeks later two weeks later there's no disease that you can see on the pet scan this is the heart it's supposed to look like that this is the kidneys and the bladder it's all supposed to look like that there is no visible cancer left on the pet scan in two weeks on bemerafinib because they have this mutation now look at this patient this special patient has diseased up and down the spine in numerous bones throughout the skeleton in two weeks with vemmaraphanin because of that mutation you can see that the disease has almost entirely dissipated so this is why molecular profiling is so incredibly important and why you need to fixate on it if you have a tumor that is theoretically incurable i want to say something here there's a lot of patients throughout the world who present like this and when they present like this they oftentimes do so in the hospital because this oftentimes will cause symptoms and so they will see a doctor who's not a cancer doctor some internal medicine doctor who's serving as a hospitalist or somebody else and that person will say oh my god you have a tremendous amount of disease you're gonna die you should go hospice there's nothing we can do well if they did that with this patient they would have cost them at least a year of good quality life because this drug is going to likely work for a year looking at this response and so that physician would have cost them a year out of their ignorance and so i want people to understand that the only time you really learn about cancer as a doctor is when you do fellowship training you don't really learn cancer as a medical school student you don't really learn cancer as a resident you really only learn cancer in your formal fellowship training so people talking to you about cancer who are not oncologists most likely know nothing about cancer so if you're talking to a hospice or talking some other doctor and they're diagnosed with the cancer the very first thing i want you to say is i want to see an oncologist and i want to see an oncologist every single time because there might be something we can do that they have no idea about they have zero clue about so the very minute you're diagnosed with cancer the next thing you say is i want to see a cancer doctor look at this patient this was just published in the neurological medicine in june this is a patient again stage four melanoma with the brac b600e mutation this patient got combination therapy which is what we do nowadays you see demographic alone when it first came out in 2010 2011 but this patient got combination therapy this is what the tumor looked like when it started look at this two weeks later look at this 12 weeks later so you can tell with me just showing you pictures i don't even listen just look at the pictures just from the pictures alone how important molecular profiling is how it can completely revolutionize somebody's treatment course look at this picture this is a patient with brca2 mutated triple negative breast cancer i told you the toughest type of breast cancer so this patient had a mutation in brca2 which allowed us to use a parp inhibitor which is a laparov is one of them you can see here that this patient initially had cancer in the right left the right breast in the right lung and in the left lung the image is reversed and so with a lapra which is a safe drug very well tolerated you can see the breast tumor got way better the lung cancer on the right is gone the lung cancer on the left is gone similarly look at this 12 year old boy with a spindle cell neoplasm this child has an ntrk1 fusion a different molecular abnormality i don't care if you guys remember them it doesn't matter don't even think about the abnormality type just see the forest don't worry about the trees this patient had a massive tumor involving the pelvis that you really couldn't resect there's no way you can take this out and get negative margins and get all of it so they took advantage of the fact that he had this fusion they gave him a drug called laritrechnid shortly thereafter the tumor shrunk as you can see here they removed it surgically nine months later he's got no evidence of disease so i need you to ask your physician if you have a theoretically incurable cancer about the molecular profile now we talked about some of the actionable mutations you just saw some of the mutations in the cancer allowing you to go to work with drugs that target those mutations but i want to focus a little bit on immunotherapy now so there's a lot of immunotherapies you've probably seen commercials for them right so there's ketruta and opdivo and eccentric and infinzi and destarlimat and semipla map and a vellum there's seven that are fda approved right now and there's a bunch in trial there's a ton toropalimab scintillamab segmolomat there's a lot in trial that are coming out we're going to come out at some point and the idea behind these immune therapies right is they rev up your immune system to attack your cancer now we have fairly crude ways of trying to determine if we think immune therapy will work in you and i already told you about them there's pdl1 msi and tmb if any of those are high i want you to immediately ask your physician if they're going to use immune therapy in your case now i want to talk about one more thing i didn't really talk about it earlier there is something called mismatch repair right so mismatch repair is a process that the body employs to correct defects in dna replication so in our body we have stem cells they have to replenish the cells we need right so typically all the stem cell that divides and forms two daughter cells now what the stem cell has to do it is it has to replicate the dna to give an exact copy to both daughter cells well that process of dna replication is not perfect there's some infidelity in that process so we have numerous proteins that are involved in repairing any genetic deficits that occur during that process and one of the ways we kind of fix those issues is with something called mismatch repair now what we know is if cancers have mutations in proteins involved in mismatch repair they can respond immensely to immunotherapy so look at this this is the new york times article published in june and i think many people saw as many of my patients rightfully asked me about it what they did at sloan kettering is he took 18 patients who had a deficit and mismatched repair 18 patients with rectal cancer stage two three rectal cancer with a deficit and mismatch repairs they were mmr deficient that's roughly about three to five percent of all colorectal cancer patients so rectal or cooling patients so they had 18 patients 18 stage 2 and 3 rectal cancer patients with this defect mmr deficiency now typically with rectal cancer patients are stage 2 3 we do chemotherapy with radiation then we do surgery then we do more chemo or we do chemo then chemotherapy with radiation and then we do surgery but what they did in this trial is they said look let's see if we can help these patients without doing any of that right so they had these 18 patients that were mmr deficient suggesting they would respond to immune therapy they gave them the starlet immune therapy all 18 of them had their cancer disappear right none of those people required surgery or chemotherapy or radiation so the book is still out hopefully those people are cured but that was a very promising result now this trial was sensationalized a lot it was sensationalized for a lot of reasons i was extremely happy for these patients but truth be told i would expect this result to a very large extent we already know in our stage four patients we do it all the time if patients have dna instability msi high oftentimes corresponding to mmr deficiency they respond to immune there so this result for me was not particularly surprising but it was still awesome look at this patient this is actually a striking result this patient had a high two mutation burden there were 76 mutations per megabase in the cancer cell that's a lot anything above tens considered high and so this patient had triple negative breast cancer they're 55 years old stage four you can see there were lymph nodes enlarged right around the aorta there was a lymph node conglomerate right by the psoas muscle and so when you look at this you're concerned right triple negative breast cancer typically does not respond to treatment very well you're very nervous fortunately because this patient was tmd high they got an immune therapy called navalnet and in two months look disease is gone but what's more important and more amazing is at four years plus the disease still hasn't come back they're still in a complete remission four years later because their tmb high they got immune therapy that worked because they're tmb high so when all is said and done i want you to be your own hero i just saw a statistic recently that was alarming i saw that in stage four lung cancer a significant number of people are not getting the appropriate molecular testing that's scary to me i'm not sure why that's happening i'm not sure if that statistic's real or not it was a study done it was a pretty valid study but done a little bit in the past so i'm hoping that's not true i haven't seen that in my colleagues but sometimes you need to be your own hero so just write these things down don't worry about the rest write down ngs tnb msi mmr pdl1 hrd take it to your position and say hey is there a role for any of this testing and if there is did you test it and can i see my results but you got to know your molecular profile i believe in this so much that we actually started the revolution cancer international molecular tuning board july 16th you can see it online we actually are getting a lot of requests from patients throughout the world to review their cases we will be doing that relatively soon but i believe in it so much that we started this please go look at that if you want now aside from everything we just talked about histology protein expression profile molecular profile you have to have to have to know how much cancer you actually have and where it's located look at these two patients the patient on the left and the patient on the right both have stage four melanoma that's b wrap b600e mutated same exact profile this is the same tumor type so when you read the note all it says is stage four melanoma so you would think that these two patients are the same but they are not that's obvious right this patient on the left has disease in the liver disease in the bones like we showed before this patient on the right has only a single spot in the right lung which is why they have stage four disease these two patients are absolutely not created equal this patient is likely to do well and could potentially be cured this is a patient of mine radiate this lesion we put them on immune therapy and i think this patient has a chance potentially being pure and so you have to appreciate that amount matters and part of the reason the amount matters is because it lets us know what the room for error is right so if i see this patient here i know for a fact i'm not going to get a second chance at this cancer i'm going to get one shot and if i'm wrong with that one shot we're in trouble so when it comes to melanoma right there's two options you have really with somebody with this mutation you can use the drugs that target that burp mutation or you can use immune therapy now immune therapy takes a long time to work and so and it also has a lower response rate and so not for a second are you going to consider doing immune therapy alone in this patient you're going to rapidly go to that braf inhibitor and the mech inhibitor the drug combination i talked about earlier to try and cure trying to extend their life with a good quality life and sure enough that's what happens patient i showed you the result but amount matters it tells you if you have room for error and it affects your attack options but location matters too so if you have disease in the bones we're going to typically give you a drug to keep your bones strong to prevent fracture that's critically important if you have disease in the brain you have to understand that a lot of our treatments that we give through the iv or subcutaneously or in a pill will not work a lot of them do not cross the bloomberg barrier so we're oftentimes reliant on radiation in fact i hate it when my cancer patients have brain metastasis because i oftentimes lose a lot of control now fortunately there are some drugs that actually cross the bloomberg barrier it's important for your physician to know that for you to recognize that because if you have disease in the brain it might make sense to use one of those drugs that gets to the brain and gets everywhere else but the bottom line is you have to know where your tumor is located it absolutely matters it helps you know how to treat the disease and to understand your symptoms now there's a scary thing i've seen in my career and the scary thing is i've seen a lot of oncologists who never look at scans not only do they not show the patient's skin they actually never look at and it always bothers me because i'm always thinking to myself well how do they know how to interpret someone's symptoms if someone comes to me and says i have pain at the l4 lumbar vertebra i'm not going to say that she needs to have lower back being but it looks like it's at l4 l3 l5 something like that right based on how their hips are located you can kind of look and see how where where the disease is in terms of the vertebra or where the pain is result with the vertebra so if i'm seeing that patient the first thing i'm doing is looking at their skin to see if there's cancer there right because i need to know is this muscle is this degenerative disc disease or is this actually cancer well how do you know if you never look at the skin similarly if you're a patient how do you know how to interpret your symptoms i had a patient yesterday that we just diagnosed with stage four gallbladder cancer she had a cholesterol just a routine gallbladder removal and the tumor invaded through the muscle layer of the gallbladder and everyone thought it was localized but i needed a pet scan because i was worried about it and sure enough we talked about this yesterday and saw it for the first time the disease is everywhere up and down the bones everywhere but this patient had had back pain for a while and she thought she was crazy she thought there was something wrong with her when i showed her the pictures and you could see that there was disease in the spine that was a relief to her she understood that she wasn't crazy and she now knew how to interpret that symptom so when all is said and done you have to know the amount of cancer you have in the location and what i really want you doing is pinning your doctor down and saying okay i want to see my skins you make them show you your scans in part that will make them look at the skin so if there's somebody who doesn't look at scans you want them looking at your skin so it will force their hand i want you to do that in addition it will make them sit down with you spend time with you and it will help you understand what's going to happen to you and what's happening to you in that moment another thing that you need to think about when you're trying to understand the team that's opposed to you your opponent you need to appreciate that no two cancers are the same in terms of their growth rates their tumor biology when i teach medical school students i teach fellows i actually did an eight hour lecture series for the roswell park fellows last year one of the things i tried to implore them to think about is something we call tumor biology and what i mean by that is how is the tumor behaving how is it acting get inside that cancer try and appreciate is it aggressive or indolent so what do i mean by that when i think about cancer i think about it as a continuum there are some that are incredibly aggressive some that are relatively indolent and you can have aggressive stage one cancers and indolent stage one cancers aggressive stage 2 aggressive stage 3 aggressive stage 4 and they can be indolent also there are some stage 4 cancer stage 4 lung cancers that you would think would be disastrous that just sit there and do nothing you can literally just watch patients it's actually kind of shocking we don't understand why that happens but it is your job as a patient and my job as a clinician to understand the biology of the cancer how is it behaving and remember what happens is always more important than what you think should happen you know we like to prognosticate we have all these different models to try and predict what your cancer is going to do and oftentimes we're wrong and we'll sit there and we'll say why are we wrong it doesn't matter right i mean it matters a little bit to try and optimize the model for the future but it honestly doesn't matter what matters is what you're seeing what's actually happening in front of you and so as a patient i want you to fixate on that to a large extent because appreciate one thing cancer doesn't read textbooks it doesn't care what i tell cancer it should happen it doesn't care and everything depends on this your treatment will depend on how fast things are growing how well things are responding your prognosis will depend on how aggressive your stage one disease is your state shooters these stage three stage four diseases and let me just talk about that a little bit more think about a patient with stage one breast cancer patient with stage one breast cancer hormone receptor positive and her2 negative they come to my office after getting surgery they have a great prognosis in general well what am i doing in that particular point well i'm trying to figure out do i need to give them chemo and how am i doing that well i'm trying to figure out where they are on this continuum do they have a highly aggressive cancer with a high risk of coming back or do they have a low growth cancer relatively indolent with a very low risk coming back and the way we do that right is we typically send something called oncotype dx we look at 21 genes in the cancer and we can kind of put it into somewhere on this continuum you can also do a mammoprint but the bottom line is you're using these tests to put it somewhere on this continuum to determine do i need to give chemo or not so it matters a lot now another thing i want to implore you to really think about here is i want you to think trends not snapshots now the natural question when you're diagnosed with stage four cancer is how long do i have leftovers every patient asks that question they should that's the question everyone should ask i despise that question i hate it i think that patients should ask it but i love having to answer it because i have no idea i don't put an expiration date on people my job is to try and keep you alive for a very long time with a good quality life in general unless you want to do otherwise but that's my job but the bottom line is another reason i hate is because more often than i'm going to be wrong i'm not god i have no idea i'm going crystal ball but also if you ask me in a vacuum based on one scan how you're going to do i have no idea right because i need to see the next picture i need to know how are you going to respond to ignition treatment you explode through the next treatment well that tells me we don't have a lot of time if you do great on the first treatment and now there's no disease on a second scan well you have a lot longer to live so i want you thinking trends not snapshots think about time points okay we started here what did the next scan show did it look amazing or not that's going to tell you a very big part of the story in addition in my humble opinion one of the most important things in stage four cancers is if you can find a time to give a treatment break certain cancers not breast cancer per se not necessarily colon cancer but certainly in pancreatic cancer where you're giving a very tough regimen called fearing ox or gym side of being a braxton you can't just keep pushing it doesn't work it's impossible to keep pushing a patient so you're constantly looking for a treatment break because you're trying to extend their life for years not months so if you're thinking for years you need to say okay i need to figure out a way to come off treatment if possible and to give them a treatment break that's the holy grail well when you try and decide if i'm trying to decide if i want to give you a treatment break if you're trying to decide if you want a treatment break or not you have to understand the risk and the benefit and how are you going to know if you don't know the biology of your cancer how does it behave if you have a cancer that's exploding in real time on you no way you're taking treatment it's impossible are you going to do that unless you want to go hospitals i get that but the bottom line is not giving you treatment breaking cancer is exploding your cancer just hanging out and i know how it behaves and i've learned it where i've spent the last couple of years with you and i know you're cancer well then i can figure out a way to give you a tremendous and so this is critically important growth rate matters and because the growth rate matters i need you to ask to see your scans again i want you to make sure you see your scans not imposition your doctor should be showing your skins you're paying like five thousand dollars for a pet scan or even more you should be able to look at your images it's ridiculous now there are so many things that the cancer is telling you while you treat a patient and you're constantly trying to assimilate that information and say okay what have i learned about the cancer here and here and here because the more you know about the opponent the better you'll do consider this patient patient of mine this is a 85 year old male with non double hit diffuse large basal lymphoma stage patient came to me in this particular situation disease in the bone disease right adjacent to the vertebra disease in the liver we gave them standard three cycles of our chop this works in sixty seventy percent of people it cures sixty plus percent of people patient did well disease regressed pretty significantly the liver is much improved this big mass has improved so we thought okay we're probably in the clear here we're going to win right you think three more cycles we're cured we're done well three cycles later disease around the vertebra gets worse this lymph node here gets worse and now you know you're in trouble you know that on that continuum where you thought this patient was going to be very well behaved in terms of their cancer you know you're in trouble now you know you're dealing with a very different beast and so now you say okay let's try something new let's show the cancer something it hasn't seen yet so now you try three cycles of different drugs that target the cancer in different ways right so cancer's seen various treatment patterns now you say okay i'm going to show it a different mechanism of action different method of attack right you don't practice insanity don't do the same thing over and over and expect the same different result you want to do something different so i showed this cancer three different methods of actionable two and sure enough cancer exploded through it and so now you know exactly what kind of cancer you're dealing with so this patient got to have acetaminophen and we're moving on from there but this cancer is very different than this one another patient of mine this patient has stage four mantle cell lymphoma a notoriously aggressive cancer so this patient you can see had a massive spleen i mean even in the world of people who do this for a living this picture is striking you will not see pictures like this very frequently it is an incredible picture we gave him treatment three cycles later absolutely no disease aside from just minimal disease in the lymph node i expect him to do extremely well and so the idea becomes pretty simple i need you to know your opponent you need to understand the histology protein expression football the molecular profile you need to understand the amount of cancer and where it's located and you need to understand the growth rate but survival tip number three you have to educate yourself now one thing that's happened in the last 10 to 15 years as me being an oncologist is that patients are becoming much more astute they're really refined and they have a tremendous amount of knowledge about their cancer and it's beautiful to watch i love it i absolutely advocate for patients to go online to learn about their cancer to press me to push me say what about this i read this i read this i read this good that's what i want you doing and the beauty is that 80 to 90 of people cancer patients search the internet when they're diagnosed eighty percent go weekly 47 go daily and 91 of these patients still go when they're confident with their knowledge that's striking but what i think is important is when you educate yourself and you advocate through education you have to have the right sources i can go through a million sources i think are reasonable i'm just going to go through two you really only need to know too i want you to know nccn.org so nccn.org depicted here is the national comprehensive cancer network it is a organization that's tremendous and there's a lot of phenomenal physicians participating in this organization that really kind of help all of us understand how to treat patients like you what i want you to do here is i want you to make an account not for patients but for physicians or for staff i want you to go here and just say okay medical staff and i want you to say okay i'm gonna make an account register it's free i want you to have the account that i do because i want you to look at tremendous details so what you'll do is you basically make yourself an account you'll go to guidelines and you'll select the cancer that you're interested in so let's say you select breast cancer so what will happen next is you'll get this screen you just click on guidelines and sure enough you'll get the breast cancer nccn.org guidelines i want you to do this you will not need to go anywhere else honestly you may supplement with other sites but this site is going to tell you exactly what you need to know so when you click on breast cancer you will see that some kia opinion leaders people who are very good at breast cancer throughout the world sit in a room and they talk about patients just like you and they tell people like me how to treat patients just like you so you can see here someone with invasive breast cancer actually tell you exactly what the workup should be what studies should be done then they tell you based on your staging which you can see on the site what should be done next i want you to go to nccn.org i want you to look at the cancer type you have i want you to go through the algorithm and to know what should happen to you now i want to be careful here these are just guidelines right they're not dogmatic and there are some times when we have to deviate from these guidelines all i'll tell you there is if your physician is significantly deviating from these guidelines you have to ask them why there should be a good reason for it now there might be a tremendous reason for it your genius your oncologist may be a genius that's awesome but the bottom line is you need to know why the other side i want to talk about clinicaltrials.gov for patients with incurable cancer stage 4 breast stage 4 liver stage 4 colorectal in some circumstances the first thing i want you doing aside from asking about molecular profile and astronaut scans i want you to reflexively ask about clinical trials i want it to be one of the first things out of your mouth what trials are available to me and i did an entire exposure on clinical trials in some of the earlier sessions you can go look at those but the bottom line is clinical trials are where we test drugs basically conduct experiments testing drugs on your particular cancer trying to provide hope where there was none we're trying to extend your life with a good quality of life through experimental therapies that are not conventionally available to you so what i want you to do is go to this site now this is what the site looks like i want you to click on the beta version up here they actually did a great thing they improved this site a lot so this is the beta version we'll just put in the cancer you're interested in location how long you're willing to like how far you're willing to travel once you do that you'll see all the trials here now one beautiful thing i think a lot of my colleagues don't even know is they actually just put a download button here now so you can actually download all these trials it gives you an excel form with all the trials that you can actually obtain from clinicaltrials.gov that you're interested i think it's awesome so let's say you click on a trial now you can actually read about it you can see if you're eligible that's what i want you doing but the bottom line is i want you to know nccn.org and that's for everyone i don't care what stage cancer you have and i want you to go to clinicaltrials.gov particularly to cancer it's incurable and go through that now i believe so much in patient education so much to clinton in clinical trials i started two companies last year that will launch next year one's in patient education one's in clinical trials doing revolutionary things these platforms i think are unique but i don't want to talk about them now it's not something that really needs to be discussed survival tip number four play chess against cancer when i see a patient i am always thinking through this comet acronym and i want you to take this comment acronym with you today this is one of the critical things i want you taking from this talk no matter what stage cancer you have when i think through my therapeutic options for a patient with cancer i think in terms of comet what are my conventional options my chemotherapies my biologic therapies my targeted therapies what are my systemic therapies what are my operational options my surgical options what are my molecular based options we just talked about why that's important what are my clinical trial options and then everything else and really i'm talking about local regional therapists so therapies we apply to a particular region about your body i'm really talking about radiation radio embolization transarterial chemicalization things like that i want you to take this acronym and every time you see your doctor i want you to say okay what are my comment based options whether you have stage one disease stage two disease stage three stage four what's the role for systemic therapy here what's the role for surgery what's the role for molecular based options what's the role for trials what's the role for radiation and i really want you to do this if you have stage four disease so let's talk about stage four disease for a moment when we see patients with stage four disease that's theoretically incurable we typically use a first line treatment until it stops working or patients can't handle it anymore then we go to second line treatment and we use that until it stops working our patients can't handle it anymore then third line and fourth line and so on and so forth i want you to play chess not checkers against cancer when thinking about this rubric and the way to do that is to say okay what are my comment based options what are my conventional options what are my clinical trial options what are my molecular based options based on my profile what are my local regional options and when you do that your doctor who should be an oncology artist should be able to take these options and make you a very nice treatment sequence based on putative efficacy how we expect those drugs to work to optimize what i call your treatment map through a practice that i call treatment cartography the idea of making cancer patient treatment sequences treatment maps that you can follow so when you see your doctor i want you to ask about these comment based options and i want you to ask them what their treatment map will be for you why is it important well a lot of oncologists might say this is too much no we need to do this well wait a second let's say i want to put you on this clinical trial in third line if i give you a drug that's involved in that trial in first or second month now i've rendered you ineligible for that trial and third line so i need to fully understand what's happening long term in addition i need to always know what my contingency plan is so i say this all the time right you don't need your cancer doctor when things are going good that's not really my job i can give you treatment that's easy to do many people just pull it off and see i just showed you how to do it it's all cookbook it's not hard to do that's not the hard part being cancerous that's not the most important part what you really need me to do is to be there when things are bad when you've run 99 the race it's all gone well you need me for that last one percent that's arduous that's hard you need me there you need me to come up with contingency plans and you need to know what the backup plan is you need me thinking ahead and if i'm not doing this if i'm not thinking through this algorithm i might be unprepared by the time you need a clinical trial now i haven't gotten you ready i haven't thought about it i don't know exactly what to do that's a very big problem we already talked about the importance of this algorithm with clinical trials and molecular profiling and i want you to reflexively ask about your common options particularly stage four and curable disease every single time you get a scan i want you to say okay what are the common based options is there a role for surgery here is there a role for molecular base options is there a conventional therapy is there some sort of radiation i need what are the trial options every time because this is going to constantly change we're constantly assimilating new information consider these patients here this patient we showed earlier stage four triple negative breast cancer treated concealer in complete remission this patient does not require a change in treatment so the comment-based algorithm is going to look very similar at this time as it did at the beginning consider this patient this patient also staged four triple negative breast cancer you can see we gave them treatment responded very nicely in the lymph nodes and in the breast that i'm not showing here but the liver got worse two new spots so this patient's comet based algorithm is going to change a little bit now i have to look for new trials because now we're three months later something else come out right do i need to reassess the molecular profile do i need to send the tissue again to see if something changed in the mutations i mean i can target something now i couldn't target three months ago so i'm always thinking about that in addition this patient is going to need a change in treatment so the underlying paradigm here is if it ain't broke like in this case you don't fix it but if it's progressing you have to show the cancer something different so you are constantly assimilating new information and the choice of weapon matters and you're adjusting on the fly survival tip number five you have to do the work i think many patients get incredibly depressed about this diagnosis that is completely understandable certainly it's been shown that 40 of cancer patients have depression but at the same time in order to really optimize the ability to fight cancer you cannot be an innocent bystander you have to be an active person what's happening is a partnership between the patient and someone like me the oncologist i can't do the work for you i can't exercise for you i can't eat for you i can't make sure you take your medications on time and i can't make sure you tell me when you have a symptom and you're hypervigilant you have to do the work now in that context i want you to know your treatment in your cancer friend of mine your dog told me recently that most cancer patients she sees in the er don't know what type of cancer they have or their treatment when they're getting chemo that is not acceptable you have to know your cancer type you have to know your treatment and you should know what day and what cycle you are why is that important because if you go to the ego and they know what treatment you're on you can tell them where you are in the treatment that allows them to address your issues more properly so it's really important you cannot be a passive bystander you got to do the work survival tip number six it's a marathon not a sprint i think a lot of patients when they're diagnosed with cancer they think there's a beginning a middle and an end and that would be nice and for some people there that's kind of true but then again it's never true and the reason for it harkens back to a shakespeare quote where he says all the world's a stage and all the men and women merely players the idea is once you get a diagnosis of cancer the stage upon which your life is played is forever altered anytime you have a symptom even after you're theoretically cured bone pain headache new little muscle thing first thing you're thinking about is this my cancer come back so even when it looks like you are done running and you're pretty much done running you're still involved in a marathon now with that in mind knowing it's a marathon and not a sprint cannot do this alone you really need to rely on your support system now a lot of patients are fiercely independent i think they're incredible and i've seen it happen all the time where patients don't impose on their family let me tell you something some of the worst pain i've seen caregivers had was when the patient didn't allow them to be there people they love you they want to be there for you they have to know that if things don't go well that they were there they can't live with the fact they weren't there for the rest of their life they want to be there please don't do this alone be kind to yourself there are going to be times when you look in the mirror you don't recognize who you are you're going to say what the hell you got to be kind to yourself you have to understand you're going to have bad days and you have to accept those you have to understand that you're not going to be able to mow the lawn all the time and do all the stuff you used to do probably that's okay you have to forgive yourself and allow yourself to just basically let that happen you need the declines to overcome the inclines you know some of the stage four patients we have we put them through chemo chemo and chemo and they are constantly running uphill that's not possible at some point your physician has to figure out a way to get it downhill is there time i can take off the treatment you've got to be thinking about the decline so you got to ask your physician is there a way to back off i'm hurting here is there a way to give me time it's incredibly important to that same end use your energy-wise always tell patients when you have cancer the ball of energy you used to have is probably going to be smaller particularly just stage four cancer you have a smaller ball of energy i want to use that energy optimally i don't want you mowing the lawn if you have someone else that can do it you don't like doing it i don't want you cleaning the house someone else can clean the house you don't like cleaning the house i want you to use that energy wisely use your support network now i always tell patients that as a physician and as caregiver there are going to be times when you're running this marathon all you need is us to hand you a glass of water metaphorically speak sometimes you'll just need to cheer you on sometimes you'll need us to be in a pace car to pace behind you and sometimes you'll literally need us to pick you up and take you across the finish line it's your job to recognize what you need and to ask for it critically important that you realize it's a marathon not a sprint and you ask for help survival tip number seven it's your boat one of the first things i tell patients when i see them is that i'm the navigator but they're the captain right it's my job to give them the options to inform them of the courses that they can take but they're going to tell us where we're going now knowing that you're the captain one of the things i want you to understand and to appreciate and to answer is is the juice worth the squeeze now a lot of people say basketball why are you saying juice and squeeze just say risk and benefit no no no no the word risk doesn't remotely entail what you go through as a patient there's a squeeze involved in chemotherapy there's a squeeze involved in surgery there's a squeeze involved in fighting cancer it's not about risk it's about the squeeze and everything we do has some sort of squeeze your job is to quantify it how much of a squeeze is this on top of that your job is to quantify the amount of juice you get for the squeeze to do that you truly have to understand your options and to do that you have to ask the right questions and the number one question i would ask if there's ever an impasse ever a fork in the road just ask your position what would you do if this was your loved one what would you do if this was your mom your dad your brother your sister your wife your husband your child what would you do understanding the squeeze component of this ratio is important and i think a lot of people forget about some of this one thing people forget about all the time is the time toxicity associated with what we do the fact you have to keep coming back and coming back and coming back that takes a lot of effort sometimes patients will drive an hour and a half two hours to come that's brutal there's a time toxicity involved you need to know that as a patient why because there are drugs that we can use to reduce the time toxicity let me give you an example there are patients with stage four her2-positive breast cancer that or say stage three stage two whatever that get herceptin and progetta okay now we can give both of those drugs sequentially in an iv over 30 60 minutes each right see there for an hour to two hours right we can do that or we can give you a drug called fesco which has both drugs in the same formulation we just give you in a subcutaneous shot over 5-10 minutes well if you're a patient why do you want to be there one to two hours when you can be there for five to ten minutes in addition let's talk about immunotherapy for a moment drug like he treated you can give every six weeks up to evil you can give every four weeks throughout that very two right you can start thinking to yourself well what would i prefer here is the drug something where i can maybe space it out so these are things you need to think about in terms of time talks financial talks to speak there was recent legislation passed where the institutions need to tell you how much they're going to charge you there's all sorts of surprises in cancer care there should not be ask them how much is it going to cost and realize that cancer is the second leading cause of bankruptcy in this country the second leading cause of bankruptcy so please please please ask about the financial talk system understand the physical cost make your doctor sit down go through the side effects with you understand what the physical cost is associated with the juice you're trying to extract mental health expense look i don't think anyone gets out of cancer unscathed it does something mentally it may not make you overtly depressed you may still be happy through it but it's doing something please appreciate that please ask to see a psycho-oncologist if you want they're they're there please appreciate that there's a mental health toxicity to what we do caregiver talks to steve people always forget this i always forget about the caregivers but caregivers go through a tremendous amount the stuff i've seen in my life has been incredible and i'm constantly fixing on the caregiver i'll talk about that in a moment but there's a caregiver talks to us okay so we talked about the squeeze what about the juice i want you to fully understand the juice understand the benefit and when you do that say okay what's the response how many people actually respond to this treatment what's the duration response when they respond how long do they stay without having the cancer get worse what's the survival benefit how many of these patients actually live long term what's the cure rate understand the true benefit and then you can make a full assessment based on the juice and the squeeze ratio the other thing i want you to understand is yes you're the captain so make sure you choose the right navigator now i teach a lot of med students fellows residents and they always ask me ask them how come your patients have the relationship they do with you but it doesn't matter the bottom line is i always tell people when i teach that you really need to give patients the best the heart and the best of mind now i think people thought when i advertised this or it was publicized that i would get on here and say i'm a great doctor i'm better than anyone else that's not true absolutely not true my mentors were much much better than me and what made them incredible at stanford in the mayo clinic the nih national chemistry institute george washington made them amazing wasn't just that they were brilliant it's that they had gorgeous hearts and they infused their heart in every single interaction that's what i want for you i want you to find a physician and oncologist who gives you the best of the heart and the best mind is pristine hearts and pristine minds because that's what you need because i'm telling you as a cancer doctor there are times when i am spent when i am completely devoid of anything left to give and in those moments cancer does not care it doesn't give a crap that i'm too tired it's going to hurt you whether i'm tired or not and in those moments when my mind has nothing left to give what compels me to find the answers is my heart it's the reason i can't go to sleep at night until i know my patients are okay it's the reason i think about them all the time you want a physician who thinks like that now how do you assess that well one good way would be do they know and do they know your caregivers so i treat patients like family right so this is natural for me to want to get inside their life like i want to get in them i want to know them right but let's talk about this first like when i'm talking to a patient and they tell me they like quilting every day the minute they stop quilting every day i know i'm in trouble and it's because i know that i understand what's happening i can identify when there's a problem early because they told me they stopped quilting similarly when i'm talking to caregivers if i have a patient whose wife's a nurse i know i'm protected i know at home i don't have to rely on him to see the inches because she will if i have someone who's in the room taking notes and loves their the person the patient in the room i know that i'm in a better situation they're not going to probably need me to watch them as closely because they'll at least report the symptoms properly in contrast if i have patients no one else in the room i know i'm in trouble now i give every piece of myself on them they have my cell phone and call me anytime i implore that person to call me because i know they're going to need me they're not going to see the interests properly necessarily i need them to call me because they don't have the caregiver support so not only is it important to get into a patient so they can you treat them like family but it actually helps you care for them next issue when you're trying to choose the navigator are they actually seeing you are you getting paid are you actually getting what you paid for it right you go to these big name institutions you see a physician assistant you see a nurse practitioner you never see the position ever is that really what you're paying for is that really top-notch care that's critically important to understand now the nurse practitioners and the physician assistants are amazing i know some are better than doctors but it's really not what you're paying for when you go to a mayo clinic or a stanford or an nih or whatever and i'll tell you that doesn't actually i'm sorry it's not work or you're going to a harvard and i'll tell you at stanford when i was with my mentors they always saw the patient didn't matter that i was in there or the pa was in there the mp was the attending the person you came to see always saw the patient at every single visit so it doesn't actually happen at stanford but if you go to other places ask who you're actually seeing are you ever seeing the position are you just seeing the advanced practice practitioner are they there when it's hard so cancer does not care about an oncologist's schedule and i'll tell you something typically patients don't die in the room they don't typically have issues in the clinic room typically happens at saturday at one in the morning or sunday at two in the morning because cancer doesn't care what day of the week it is or what time it is and so what you want to know is is your physician going to be there when it's hard it's super easy to be when they're there when it's easy you need me to be there when things are hard when you wrote 99 the race and that was easy that last one percent if you don't finish it when it's hard it's like you didn't run the race and you need me there in that one percent so what you ask is you say okay what happens if i'm super sick who do i call are you going to be there in the hospital are you going to round on me you can actually take care of me when i'm at my sickest when i'm getting symptoms for what you did that is critically important does the physician teach do they show your images do they spend time with you are they seeing in the hospital clinic all of these are important choose physician over institution okay there's tremendous institutions institutions are important but they are not more important than your physician you know always kind of laugh a little bit because people will talk about these big name institutions they're getting the same exact drug that other communities oncologists are giving same literally is an exact drug it's exactly the same drug not do anything differently and so remember physician over institution institution matters though because they will oftentimes have clinical trial options that are important so you just stage four cancer you ask about clinical trial options and choose the place you go based on the clinical trials that are available to you and some other things i just discussed this is an example of what i do in rooms so i have hundreds maybe thousands of these whiteboards actually where i'm literally the first time meeting people teaching them about their disease literally going through everything because i firmly believe that education manifests as improved survival so i go through all of this with patients in profound detail almost to the level being pedantic survival tip number eight know the down and distance when you have patience in your office and you as a patient it is very different when it's first in goal and you're about to score touchdown than if it is third and ten and you need to pick up yardage and the reason that matters what we discussed earlier if it is fourth and 31 and you have disease like this that is no time to play games that is no time to try and do experimental therapies something that's undoubtedly not going to work when you've got something conventional you know is going to work that is not time to play it's fourth and thirty one if it's first and ten now all options are open you can start to think about what to do because you have a lot more room for error so it matters down in distance absolutely matters it impacts treatment approach and you are constantly reassessing this right it doesn't just stay first intense nothing's static in cancer care cancer's not waiting on you and saying okay first and ten you win that never happens right so you're constantly reassessing down and distance because you're going to make you're going to determine your treatment options in part based on that and i want you to it helps answer a lot of questions specific to you right if you come to me and say bastard how long do you think i have left to live well what's the down and distance are we fourth and thirty or are we first intent it impacts so many questions you're going to have what treatment you're going to get how long will i have to look to live what symptoms are going to feel well what's the down and distance consider this example this is a patient of mine with an elk fusion positive stage four lung cancer stage four lung adenocarcinoma so we initially treated him with a drug called burgatin it when he first came in you can see a disease in the lymph nodes in various locations armpit middle of the chest neck so we treated him with forgotten things look great two months later it's awesome no disease here you can't see that very well but there's no disease left he's in a complete remission he does great until january 2022 so now he's had roughly what so roughly 16 months of having no disease progression nothing has transpired so basically when we started we're first in ten down seven zero three months two months later we're winning we're up we're tied seven seven sorry so it's first in ten seven seven now all the way in january no progression we're winning we're up 14 7 it's first and ten okay good now there's a lymph node here so we say all right there's just a small lymph node i don't need to start chemo yet let me just switch gears and do a different a different alkyl hiv or a different drug that targets that fusion okay so good we're first and 10 up 147 we can play around a little bit well wait a sec now you've got a new pleural effusion there's new malignant fluid here you can see that there's disease in the pleura now so now you lost yardage now it's second and 20 and you're tied fourteen fourteen the score is tied you're no longer winning so now you say okay i don't have time anymore i have to go to chemotherapy i actually use them in there because there's po once 95 that's a little debatable i admit that but the bottom line is now in june 2022 you just scored another touchdown you're up 21-14 it's first and ten he's in the complete remission we're winning patience winning so survival tip number nine be loud demand to see your position not just the pa and the nurse practitioner demand time and education from your physician demand to see your scans demand to see the comet options walk in the door comment acronym in front of your face okay what are my conventional options my operational options my likelihood options my trial options and everything else ask for a second opinion dissatisfied don't worry about the ego of your doctor who gives a crap ask for a second opinion and when in doubt call always call survival tip number 10 take cure seriously there is a big difference between cure and treating someone to just keep them alive with a good quality of life i want you to take your seriously appreciate that when you look at a scan with a one centimeter spot that thing is tiny it's less than half an inch right two point five four centimeters an inch less than half an inch that's a hundred million cancer cells so if you have point one millimeter tumor that's one million cancers i'm never going to see it on the skin that's why we give patients chemotherapy radiation after we do surgery we're trying to clean up the cells we can't see and why because we put our foot all the way on the gas because we're trying to make sure your cancer does not come back because there's a world of difference between being cured and having a disease that's incurable ask about curative options at all times now early stage disease you should be readily cured right so go to nccn.org look at the curative approach and make sure that you're getting something that resembles that but sometimes you'd be surprised who you can cure even as an oncologist like me i get surprised look at this patient here this patient has stage four colorectal cancer they had had a number of resections chemo and the disease exploded afterwards you can see all these spots in the liver so what they did is they did a liver transplant they actually transplanted his liver and three years later there's still no disease anywhere in his body they potentially cured him with a liver transplant for stage four colon cancer there are people doing this in the states mayo clinic jacksonville is doing liver transplants for patients with stage four colorectal cancer that is not something that is intuit that is not something we typically think of and i guarantee you a lot of oncologists don't really think about this when thinking about stage four colon cancer patients but remember to ask about cure and to push the envelope now this gets a little bit crazy right i'm still not sure how i feel about this because the amount of squeeze involved in a liver transplant for the juice that you're trying to extract may not make sense and every patient's different and so as a oncologist who treats everything but in a lot of stage 4 colon case i'm not sure how i feel about this yet i haven't seen anyone for a liver transplant but the bottom line is something you may think is incurable may not be look at this patient here this patient is a patient of mine with hodgkin lymphoma it's 85 year old copd hodgkin lymphoma this patient has an 89 chance of being cured of their disease being cured this is not a time to play games it is not a time to talk about supplements that are unproven it is not a time to go to mexico and do something that's unproven this is a patient with a highly curable disease go with conventional therapy that works until the idea here is he got two cycles per toxin having two cycles of abd chemo and he's doing extremely well he still has a little bit of work to do he's doing awesome so take cure seriously control the variables so i tell people all the time not just in cancer in life in business control the variables what i mean by that if you're trying to figure out why there's a problem don't make 10 changes once you do 10 changes at once you're not going to know what worked what didn't work do one thing at a time control the variables in cancer care i'm very careful to control the variable i teach this it's a refined approach i only make one change if i can at a time i take one thing away i'll add one thing because i want to know exactly where we are to this end it's not the time for unknown and new supplements they introduce a ton of variables imagine this you're taking a supplement i don't know i have no idea what that does in your body right now i'm giving you chemo and now your liver function enzymes go through the roof now there's a big problem with the liver i don't know if it's the chemo i gave you or it's the supplements you took that's a very big issue it's going to put us behind the eight ball because we will not understand what's happening to you so this is not the time for new supplements it's not the time for unproven therapies now listen i'm a big believer i don't know what i don't know some of these treatments may work i'm not saying there's no validity to them but it is not the time to play around and please know that we are on your side you know a lot of people come to me i want to go to mexico i want to go do this i want to go do that i'm on your side like if there was something i could give you that would cure your cancer and put me out of a job i'd be the first person to give it to you like i would love for for me not to have a job i always tell people you want me to be useless i want to be useless like i would love to go find something else to do i'm not sure what i would do i could find something else to do so the bottom line is we're on your side but there are a lot of people with bad intentions a lot of people online trying to steal your money and it makes me mad you know i i'm so in involved in my patients i actually get viscerally angry when scans get worse i get pissed at the cancer i can't even explain it i get mad similarly i get mad when patients are being taken advantage of i get infuriated there are a lot of people online who will try and take advantage of you back 60 minutes did a huge expose on how a significant number of supplements you buy at the store walgreens cvs target and walmart don't even have what they say is in it so this is not a time to experiment it's a time to try and take cures seriously so ultimately these are the 10 tips that i think you need to optimize your ability to fight cancer the inches matter know your opponent educate yourself play chess against cancer you have to do the work it's a marathon not a sprint it's your boat no down in distance be loud and take cure seriously final thoughts your journey is unlike any other when you have met one person with cancer you have met one person with cancer try and appreciate the personal personalized nature of your journey be the best patient you can be i know that sounds cliche it sounds stupid but i mean it know your treatment know your cancer type know what symptoms to look like to look for tell me when there's an inch that's being compromised you have to be the best patient you can be ask for help loudly don't worry about imposing on your cancer doctors what they're being paid for don't worry about asking to see your scans be loud you don't have an expiration date please remember you don't have an expiration date go through the comment algorithm play chess against karen so cancer think outside the box think about clinical trials molecular profiles you don't have an expiration date and hope springs eternal you know when i was four years old first time i saw a cancer cell there was very little anyone could do about cancer now the field is exploding like every day there's new drugs we hear about it's awesome and so as i teach my sons this is my twin boys about cancer and i show them cancer cells under the microscope what i try and impress on them is that this field is exploding and there's so much we can do now that we couldn't before so her hope does really spring eternal lastly i'll just say that we are doing this every week this particular cancer patient education series you can see us on revolutioncancer.com this is not being monetized not being sponsored i'm not being paid this is solely because i'm trying to give patients as much as i can before i die trying to touch as many people as i can in the shortest time frame possible thank you for coming appreciate it i will take questions sorry sorry i'll take questions hold on let me just unmute people does anyone have any questions any sort of just raise your hand if you have a question so hold on all of you has a question about me okay hello bossam fabulous presentation wonderful information two questions for you um one could you just review again who are the best candidates for immunotherapy and two um i know you've talked about this in the past uh just your thoughts about the grail test and its effectiveness yeah so when we talk about immune therapy just understand we have very crude measures right now of trying to figure out who will respond to immune therapy and who won't so we look at things like microsoft instability pl1 status we look at two mutation burden if you're high or in special repair if you're high in any of those or you're mismatched per division we think you'll respond to immune therapy you're more likely to respond but there are a lot of companies right now trying to develop immunotherapy prognostic assays to try and refine our ability to determine who will respond to immune therapy or not so oncocite onco host boston gene neterra they all have tests that are trying to get better at predicting who will respond to immune therapy with respect to the gallery test being made by grail so for those that don't know i wrote an article about this on biofrom return.com that test professes to be able to look for 50 different cancers in a single blood sample they want to essentially be an annual cancer screening test for patients at every single physical exam visit and i think that that test still has a lot of validation that's required behind it it looks somewhat promising at least for later stage tumors it doesn't do a great job for early stage disease and so it's still a little bit problematic they have a lot of work to do still before i think they become mainstream but i will say that people are already prescribing it so 2400 physicians in this country are prescribing this test anybody in this room can get that test it's potentially better than nothing it's actually quite striking but just realize that there are a lot of false negatives with this test so just because it says you don't have cancer doesn't mean you're on cancer so i think there's a lot of work to do thank you my pleasure any other questions from anyone else well i can't tell you how much i appreciate everyone being here thank you so much for being here it's extraordinary to have you here we'll be back in a week please take care everyone thank you so much have a good one