Considering that over 40% of U.S. adults have obesity and there are fewer than ten thousand obesity medicine specialists, PCPs are a critical part of the solution as we tackle this epidemic. While PCPs have extremely limited time to delve into the complexities of obesity and provide support between visits, it’s wonderful when they are knowledgeable about evidence-based obesity treatment so that they can at least initiate the conversation and refer their patients to an obesity specialist.

But the collaboration doesn’t stop there. Obesity is not only a chronic disease in its own right; it is also associated with more than 200 other conditions that can affect all body systems. According to data from IQVIA, people ages 40-64 with obesity have 2.4 comorbidities on average. That figure rises to 4.9 for individuals 65 and over (and 7% of people in the latter age group have 10 or more comorbidities). Effective treatment requires taking these comorbidities — and the medications often prescribed for them — into account and communicating with other members of the patient’s care team throughout treatment.

The following are just a few of the subspecialties that obesity touches.

• Cardiology: The impacts of obesity on cardiovascular health — raising the risk of high blood pressure, heart attack and stroke, among other conditions — are among the best known and most thoroughly studied. In fact, the anti-obesity medication, Wegovy, was recently approved specifically to reduce the risk of adverse cardiovascular events in individuals with obesity and established cardiovascular disease.

• Endocrinology: Adipose tissue is an active endocrine organ that produces more than a hundred different hormones, so it’s no surprise that endocrinologists are frequently involved in treating obesity-related conditions — Type 2 diabetes being the most familiar, but also polycystic ovarian syndrome and infertility, among many others.

• Orthopedics: Obesity is a risk factor for the development of soft tissue damage and osteoarthritis in load-bearing joints, particularly the knees, due to both inflammation and mechanical stress. Joint pain then inhibits physical activity, which worsens obesity, creating a vicious circle — while also increasing the risk of complications associated with orthopedic surgery.

• Oncology: Obesity is a risk factor for the development of many types of cancers, including breast, colon, rectal, pancreatic, kidney, esophagus, ovarian, skin, liver, thyroid, gallbladder, brain (meningioma) and endometrial cancer. Researchers believe that excess body fat leads to hormonal and metabolic changes that trigger inflammation and promote tumor growth.

• Gastroenterology: Obesity is associated with many digestive system diseases, including gastroesophageal reflux disease, esophagitis, gallstones, metabolic dysfunction-associated fatty liver disease and cirrhosis, and various related cancers.

• Pulmonology: Individuals with obesity face a higher risk of asthma, obstructive sleep apnea and other respiratory conditions (including, as we observed with COVID-19, potentially worse outcomes from viral infections).

• Psychiatry: Obesity and depression are closely linked, with a bidirectional association, and it’s worth noting that many antidepressants can promote weight gain, so prescribers should be prepared to consider weight-neutral or weight-loss-promoting alternatives for patients with obesity when possible. Other common mental health comorbidities include anxiety and eating disorders.

For many of these obesity-related health complications, losing weight can be the first line of treatment, and the relationship is often dose-dependent, meaning that these conditions worsen as obesity worsens and improve as obesity improves. This correlation may lead us to instinctively reach for GLP-1 medications as the most effective option, since we want to help our patients lose as much of their excess weight as possible and experience the greatest benefit. But especially considering significant cost, coverage and supply constriants, other anti-obesity medications can still bring measurable health benefits and might even be preferable for many individuals. Losing just 5% to 10% of body weight can lead to clinically significant improvements in markers such as blood glucose, cholesterol and blood pressure.

Improving patient health — not just reaching an arbitrary number on the scale — is the ultimate goal. Obesity touches everything, and treating obesity can have a positive, cascading effect on other conditions. If we can help a patient achieve Type 2 diabetes remission, reversal of sleep apnea or improved fertility, we’ll have made a real difference in their life.

The post Obesity Touches Everything appeared first on Medika Life.

The LLM Cancer Mentor App is a revolutionary tool for cancer patients, caregivers, and physicians. It’s like having a WAZE for navigating the complex cancer diagnostic and care journey.  No longer do patients have to wait for their next appointment to get answers to their questions. They now have a high-level concierge coach available 24/7, ushering in what innovation theorist John Nosta calls ‘The Age of Cognition ‘.

“Perhaps one of the most complex things about oncology is complexity itself. From clinical knowledge and understanding to articulating difficult concepts with patients. Part of what large language models (LLMs) offer is the ability to provide a cognitive assistant that serves up information that is organized and important, and delivers it away that is more relevant and understandable,” said Nosta to Medika Life. “This is perhaps most important with patients who often find the complexity of oncology to be one of the worst toxicities of both therapy and disease,” he added.

ChatGPT Controversial Perhaps, But Patient Preferred

Last year, a controversial JAMA study suggested patients often preferred ChatGPT tools to physician conversation.  A chatbot generated quality and empathetic responses to patient questions online in this cross-sectional study.  While physicians doubted the study’s design, it was evident from data and public conversation that technology available in real-time answering patients’ pressing clinical and emotional needs was sought and welcomed. Even Eric Topol, MD, a long-time AI advocate reports that augmented information can potentially save lives.

Now, the large language model (LLM) called Dave AI was created by Belong.Life increases patient engagement and provides personalized support.  Medika Life spoke with one of the world’s foremost digital health leaders, who marshaled the potential of technology and tapped medical and drug development experts and patient feedback systems to develop AI, ChatGPT, and LLMs tools to support cancer patient advocacy and innovation.  Eliran Malki, the co-founder and CEO of Belong.Life, is a proven entrepreneur and business leader who has founded, financed, and led several successful companies, including More IT Resources Ltd., acquired by Dell-EMC, Veracity Ltd., acquired by EMET, and others.  Together with Co-Founder Irad Deutsch, they launched Belong.Life almost a decade ago. Today, the company serves patients around the globe.

Malki’s blueprint for success isn’t a closely guarded secret – he consistently creates tech platforms that provide easily accessible, practical, and consistent value to users.  Belong.Life is a multilingual HIPAA, GDPR, and ISO-compliant community combining science, service, and solutions to unite patients, payors, product innovators, policymakers, and provers. It demonstrates that the LLMs can provide patients with the support essential to their cancer care journey – augmented information on-demand.

[The  Dave Cancer Mentor app can be downloaded here.]

Dave AI Created to Improve the Patient Journey

Eliran Malki, Co-Founder and CEO, Belong.Life: Dave AI was among the reasons we launched Belong Life – to improve people’s care journey and, ultimately, possibilities for outcome success. We trained this unique LLM (large language model) on an extensive knowledge base of 80 million discussions between patients and physicians. Over eight years, it’s accumulated knowledge of numerous physicians with 100,000 patients discussing the Belong Life app. The training process involved anonymizing and aggregating data to ensure patient privacy and security.

Gil Bashe, Editor-in-Chief, Medika Life: Incredible, eight years and 80 million discussions. How did you distill millions of exchanges and infuse them into Dave AI’s mind? Could you explain the process?

How Does the Dave AI LLM Work?

Malki: We started about six to seven years ago. There are a lot of questions that sometimes people lack the confidence to ask their physicians. People too often have only 10 or a maximum of 20 minutes with their provider. Patients want to ask the top two to three pressing questions, but you don’t do that if you are shy or intimidated to raise a topic.  At the same time, physicians want nothing more than help. Dave AI is a bridge between patients and their physicians – it helps prepare and strengthen the person-to-person relationship.

Here is a video summary of how Dave AI works:

With Dave AI, you can ask about treatment options, potential therapy side effects, clinical trials, or even managing your symptoms – pain, sexual function, or personal care. You’ll receive a supportive, comprehensive answer that covers all aspects of your query. We want to give the best services to patients at all hours, day and night, to educate and empower. Dave AI enables us to support millions of patients and prepare them to use their time with physicians productively. Everyone can get maximum support immediately. It’s suitable for payors, good for providers, and, most importantly, for patients.  It’s a model that combines the best of medicine, patient-physician relationships, and technology.

Dave AI Access for Everyone was Important to Belong.Life

Bashe: I have a question about cost. I understand there’s a free app download on any platform at no cost to the patient.

Malki: Yes, free of charge. We created three service levels to ensure this LLM technology is accessible to all.  The new Dave AI Mentor app is a free zone with premium services. The Dave AI Mentor answers questions and works with patients as a navigator along their cancer journey. It will ask about your upcoming tests; it will help people keep a diet and exercise regimen on track. Depending on your journey, it will be a health case manager and a constant ally. Dave AI will call you and answer questions that you ask, and it will also ask you questions to help model engagement. It’s similar to a coach,

We’re doing many things with hospitals, physicians and insurers that now cost $14.99 monthly. If you are an insurer, you can offer a patient, Dave AI, as a mentor or a case manager who’s available 24/7 and provides support with education and information for $150 per year. It’s the same for hospitals.

Bashe: So, are there different levels of Dave AI services to provide for people with varied economic and information needs?

Malki: Correct. There is a free version, a Pro version, and a Power Plus version. Everyone gets a seven-day trial to use everything. Most users renew. We start billing in January. If people don’t want to pay for an entire year midpoint in the cycle, they can use the free version first.  Many patients prefer the yearly subscription at $120 to $179, which offers unlimited access and added services.

Bashe: I’m curious – do you white-label Dave AI for hospital systems? For example, would it be possible for centers of excellence such as Memorial Sloan Kettering or Hackensack Meridian to secure a branded version of Dave AI catering to their patient needs?

Malki: Yes.  This is central to our service and patient care efforts. We are a technology company.  But we are, first and foremost, a patient-care service platform.  We want people to use and access the best of technology to improve their health.

Bashe: I wanted some background about basic free Dave AI. Now, some people are economically hard-pressed at the same time. Though $149 per year is not a lot when your life may be on the line, you have ensured that there is access to all, regardless of economics. How do Dave AI, Dave AI Pro, and Dave AI Pro Plus differ?

Imagine an Interactive Cancer Expert Available 24/7

Belong.Life’s new oncology AI mentor, Dave, provides accurate, personalized and accessible information instantaneously for people navigating the cancer journey. Dave is available on Belong’s Beating Cancer Together app.

Malki: Some people post 2,000 questions – some read  more than 5,000 posts.  Access to Dave AI for all is essential.  At the same time, someone speaking with an expert resource for 2,000 posts and chats should become a subscriber to the service because it is an incredible investment for us to create, operate, and continuously perfect the system.

Bashe: How many questions can you ask from the free Dave AI before going from Dave AI Pro to Dave AI Plus?

Malki: The free version is limited to 10 questions; the user must wait a week afterward—10 for the first week and then five per week. Many patients value the service, realize its immediate benefits, and are willing to pay. Taking a photo of a clinical document – uploading diagnostic test results – and understanding the document while you are still in the MRI waiting room is an incredible benefit, rather than waiting before you see the physician to discuss the written report. It is of considerable value that Dave AI can read, analyze, and provide feedback almost immediately.   

Scheduling a meeting with a physician is time-consuming and emotionally consuming. You call to wait days or weeks – a day feels like a lifetime.  Sometimes, you need questions answered immediately, seek elaboration, and say, “Please explain again; I didn’t understand that.” So, Dave AI is crucial for patients’ care and mental well-being.

Bashe: With Dave AI Pro Plus, people can ask as many questions as possible?

Malki: Yes.  As many as you want, all the time, 24/7.

How Does Smart Tech Get Smarter?

Bashe: I wanted to get a sense of the evolution of Dave AI. So, I understand that Dave AI is very smart today. How does Dave AI maintain that high level of intelligence week after week?

Malki:  Great question. This is a unique and critical accuracy feature that we patented.  It’s known as the Arch Methodology. The Arch stands for Accuracy, Responsibility, Compliance, and Hallucination-free. AI must always answer accurately; if Dave AI doesn’t know the answer, he can’t invent it. He will say, “I cannot answer.” Telling the AI what not to answer is as important as telling them what and how to respond.

We have several LLM multiplexers. [AS1] This is also one of our patents. All information goes through feedback classification, sentiment analysis, an RLHF Engine (Reinforcement Learning from Human Feedback), and a machine learning approach combining human guidance to train the AI tool..

Every change also goes through several tests and the automated ARCH-validated protocols.

Speed Accelerated for Clinical Trial Inclusion

We have been offering a clinical trial recruitment service for patients for the past six years. The average time for matching a patient to a clinical trial before  September 2023 was 5.4 days from when the patient started speaking to us.. Once we launched and added another LLM called Tara to our clinical trials matching program, the median connect time was 9 minutes, and the average was 2 ½ hours. The patient also can upload their documents, and the system will do all the work.

Eliminating the Tension of Waiting for Answers

The BelongAI Dave – Cancer Mentor app provides 24/7 accurate, personalized, and proactive support and information for people navigating the cancer journey.

Bashe: If you have 15,000 patients, those are 15,000 people who don’t have to wait 5.4 days.  There is also the issue of reducing anxiety levels for someone who has just been diagnosed with cancer. How do they take control of a situation when their life is out of control? They collect information and act on it. If they’re lingering in the trial search environment for five days or three days, that increases their anxiety levels. If they search for only three hours, that reduces their anxiety level.

It’s a little bit like having an interview for a job, and you’re waiting 5-6 days to find out if you got the job, or if they call you back in 3 hours and you got the job, what’s your anxiety level while waiting to hear about the job? It’s off the charts. By day 5 ½, you’re wondering why you didn’t get it.

Unintended cruelty is baked into the clinical trial enrollment and care system, which keeps people hanging. Dave AI and Tara AI eliminate that factor.

Malki: It gives them hope. The patient asked for and got information relevant to the clinical trial, whereas people generally wait till a physician tells them.

Bashe: The reality is that Dave AI hones the process. The patient isn’t necessarily going to run off and enlist in a trial; they’ll say to their doctor, “Look, I’ve gotten three possible trials from this database that fit my profile; what do you think?” It’s not an exclusion of the doctor; it’s accelerating the doctor’s ability to look over information and reply. Technology is not a replacement for a doctor; you understand that democratizing decision-making accelerates your enterprise’s decision-making pace. Same with the doctor.

The doctor, who’s cognitively sharp and psychologically sturdy, now has a patient who is much more engaged with the system. It’s not that Dave AI is the only trusted source; it’s that Dave AI is accelerating the patient’s ability to engage their doctor. The doctor can speak to the patient for five minutes and say, “I looked over your stuff; I think these are three good choices; I would go with this one as the priority, and tell me when you’ve enrolled.” The doctor never loses control over the patient. Oncologists want patients who remain alive.

I have a key question I will make sure to grab: How does Dave AI today get smarter tomorrow? What’s the rate of ability to make Dave smarter?

Malki: There are several factors involved in being smart in AI.. If you want chats, you will need Open AI, Gemini , or something like that, as you see in a mixed style, or Falcon, which is among the best. There are top five in the world as generative AI, and we’re just using three of them, running them on our classifications and our data – there’s no one in the market with our data. No one has the same physician-patient discussion database.

What makes us much better is that we added data from Dave AI’s patient exchanges. We deploy these patient discussions, remarks, and feedback. Dave AI is continuously improving.

Layers and Levels to Ensure Accuracy

Malki: 

We took the platform of AIand built three levels of what we call autonomous AI. Level 1 is controlled;. This is the easiest step forward for pharma, the FDA, and regulations. Gen 2 – this information is 100% accurate because the first one is pre-defined and pre-scripted; I have the approved answers, and the physician sends the second one.

Level 2 is a generative AI agent for specific documents, only . That’s amazing for hospitals, especially for logistical or administrative questions. Information that can lower stress and free the professional team.

Level 3 is a fully automated conversation with AI.  This is a Highly scaleable and valuable solutions

Bashe:  We’ve entered the cognitive age. With large language models, you’re in conversation. It understands that there’s a conversational tone to every exchange. You can use the LLM for half an hour or 40 minutes until you feel you’ve exhausted your train of thought.

Malki: Every payor, every provider, and every patient needs access to these platforms  as triage services to lower stress – the burnout level for professionals and increase the value to patients.  To review for Medika readers, here are the three Dave AI service options:

Dave Pro:

• Proactive check-ins with users about previously discussed concerns, scheduled treatments, and more.
• Precise, comprehensive, and empathetic answers to cancer-related questions and challenges.
• Document analysis and explanations of clinical terminology in easy-to-understand language.
• Access a personalized, continuously updated library of information on treatment options, side effects, and emotional well-being.
• Medication management, appointment notifications, and reminders.

Dave Pro Plus offers Dave Pro features through Tara, Belong.Life AI-powered assistant that matches patients to clinical trials based on their unique medical situations and locations. Through ongoing searches, Tara identifies new treatments and clinical trials and shares easy-to-read monthly summaries to update patients on treatment possibilities.

Dave Community allows patients to interact with Dave in a public forum, enabling users to understand other patients’ challenges and interactions with Dave.  

So, what do doctors think about Dave AI?  

We spoke with Ilya Iofin, MD, the Chief of Orthopaedic Oncology Service at Mount Sinai Hospital.

“Thank you, Gil. I first started working with Belong in 2017 or 2018.  Dave AI gives accessibility because you have this additional resource where anyone can understand the answer. AI is trained and based on what physicians say. You can use medical lingo and confuse everybody or try to explain it in terms that a reasonably intelligent person can understand. I think AI will do the same thing if AI learns from physicians who can get their thoughts and information across in reasonable human speech.

“Specialized medicine, especially oncology, differs from any other field. I’m a physician. If I talk to a car mechanic, he needs to explain, in terms I understand, how a car and engine work. Or I’ll just be as confused as the guy who knows nothing about cars. That’s the benefit of this LLM for people confronting cancer.”

Welcome to the Age of Cognition

Dave AI and LLM enable patients to navigate the complexity of medical care – from diagnosis to treatment to being in dialogue with their care team – which are critical to outcomes.  Malki and his team of engineers, physicians, medical professionals, and patient allies are showing us that LLM is not space-age technology.  LLM enables people diagnosed with cancer to overcome one of the disease’s biggest challenges: learning a language they never thought or wanted to understand.

Patient Advisory

Medika Life has provided this material for your information. We note that this platform and information provided are not intended to substitute for the medical expertise and advice of your health care provider(s). We encourage readers to discuss any clinical decisions on treatment or care with a health care provider. The mention of any product, service, or therapy is not an endorsement by Medika Life.

The post LLM Cancer Mentor “Dave AI” Offers WAZE-like 24/7 Personalized Support, Making it a Game-Changer in Patient Care appeared first on Medika Life.

Up to 30 percent of individuals with cancer have tried a so-called “cure” that is futile medicine, potentially wasting time and money. In addition, use the wrong alternative medicine, and you may put yourself in harm’s way.

Today we explore three popular complementary approaches to cancer management: high doses of vitamin C, cannabis oil (including Rick Simpson Oil), and herbal remedies.

1. Vitamin C

Many of my patients believe that very high doses of vitamin C is a good cancer treatment tool. From where did this idea come?

Research in the 1970s suggested that the nutrient is toxic to cancer cells. While initial research hinted at the promise of vitamin C as an anti-cancer agent, subsequent analyses showed these studies to be flawed.

Let’s look at the high-level evidence suggesting vitamin C doesn’t fight cancer and may create expensive urine. Large randomized clinical trials showed no drop in cancer incidence for those consuming vitamin C supplements.

For instance, the Physicians’ Health Study II randomly assigned over 14,000 males 50 years or older to receive vitamin C (500 milligrams daily) or a placebo for eight years. No differences in cancer incidence emerged between the two groups. An additional three years of post-study follow-up revealed no differences in cancer (or prostate cancer, specifically) risk.

Turning to females, the Women’s Antioxidant Cardiovascular Study included almost 8000 females. Consumption of vitamin C 500 milligrams daily for 9.4 years did not affect cancer incidence.

There can be some downsides to vitamin C supplement use. For example, vitamin C increases your kidneys’ excretion of oxalate, raising the risk of kidney stones.

Look at the results of an observational study with over 23,000 males (without kidney stones) followed for 12 years. Vitamin C supplementation appeared associated with a near-doubling (relative risk 1.92) of the risk of developing kidney stones.

But there’s more: Recently, researchers have shown that vitamin C given through a vein (intravenously) can have different effects than the pill form. Might vitamin C reduce radiation therapy side effects? Chemotherapy toxicity?

I could find no high-level evidence that we should use Rick Simpson Oil (and other forms of cannabis oil) for cancer treatment, even as some early studies show promise.

I am cautious and would wait until we have better evidence before advocating for the routine use of vitamin C. When IV vitamin C is combined with certain anti-cancer drugs, the anti-cancer drugs may not work as well. Kaiser Permanente provides a nice overview of intravenous vitamin C:Intravenous Vitamin C (PDQ®): Integrative, alternative, and complementary therapies – Patient…Vitamin C is a nutrient found in food and dietary supplements. It is an antioxidant and also plays a key role in making…healthy.kaiserpermanente.org.

In addition, case reports show that individuals with an inherited disorder called G6PD deficiency should avoid high doses of vitamin C because it may cause hemolysis.

Because vitamin C may make your body absorb iron more readily, high doses of the vitamin are not a good idea for those with hemochromatosis (here, the body takes up and stores more iron than it needs).

2. Cannabis Oil

Created from marijuana plants, hemp or marijuana oil has no good evidence that it can kill cancer. Admittedly, cannabis may ease some cancer treatment side effects, such as nausea and appetite loss. If you are considering using this drug, please discuss it with your cancer doctor before using it.

Cannabis oil comes in many forms, including cannabidiol (CBD) oil, often part of medical marijuana. Unlike many other cannabis oils, Rick Simpson Oil is high in tetrahydrocannabinol (THC), the primary psychoactive chemical in marijuana. THC is the marijuana chemical that provides the “high.”

Rick Simpson Oil (and other forms of cannabis oil) don’t have high-level evidence to support their use for cancer treatment, even as some early studies show promise.

Some studies in the lab and animals show THC and other cannabis chemicals have anti-cancer properties, including blocking cancer cells from spreading. I look forward to seeing what ongoing research reveals. And remember: While well-tolerated by most, cannabis can have toxicities such as memory impairment and attention loss.

3. Herbal Remedies

Herbal remedies do not prevent or treat cancer. Moreover, using herbal tools may lower the effectiveness of anti-cancer tools such as chemotherapy and radiation therapy.

On the other hand, some herbs may ease cancer treatment-related side effects. Ginger, with its anti-nausea properties, may help some. The evidence, however, is mixed.

The American Society of Clinical Oncology (ASCO) 2020 guidelines offer that the evidence is insufficient for a recommendation for or against using ginger to prevent chemotherapy-induced nausea. So I would offer that using herbal remedies such as ginger is not a hard “no,” as my title implies; rather, talk to your cancer doctors about their use.Herbs and Spices in Cancer Prevention and TreatmentMore than 180 spice-derived compounds have been identified and explored for their health benefits (Aggarwal et al.…www.ncbi.nlm.nih.gov.

Several Cochrane reviews show no convincing evidence (in the form of randomized trials) to support Chinese herbal medicine use as a treatment for esophageal or lung cancer.

In addition, a study of chemotherapy (gemcitabine) with or without Huachansu in patients with locally advanced or metastatic pancreas cancer showed no benefit from the combined approach.

If you decide to try a complementary approach to cancer management, please let your cancer management team know what you are doing. Some non-traditional approaches may compromise the traditional treatment effectiveness.

Thank you for joining me today.

The post Say No to These Cancer Remedies appeared first on Medika Life.

Do I think that the research is good enough to have our patients adopt the practice of a fasting-mimicking diet? No, the study does not conclude that such an approach to nutrition has antitumor effects. Let’s look at the study’s merits.

The study authors begin with this observation: In mice with cancer, cyclic fasting or fasting-mimicking diets (FMDs) enhance the activity of anti-cancer treatments by changing systemic metabolism and boosting anti-cancer immunity.

But what about humans? Can a similar dietary approach yield similar effects? To find out, researchers examined 101 patients undergoing treatment for either breast cancer or melanoma. They asked the study participants to do this:

Consume 1800 kilocalories in five days (more specifically, 600 on the first day and up to 300 kilocalories for the remaining four days). The subjects repeated the cycle every three to four weeks. The patients had no diet restrictions in-between cycles, but the investigators recommended a healthy diet and lifestyle.

Here are the results of an interim analysis of the ongoing DIgesT trial, testing a 5-day fasting-mimicking cycle seven to ten days before surgery.

First, dietary interventions (such as fasting) are often challenging for patients to follow. Not for this study: 92 percent complied with the diet approach.

The patients successfully modified both body and within-tumor metabolism and immune response with compliance high.

The average blood sugar concentrations dropped by 19 percent, and insulin levels dropped by 51 percent. Serum insulin-like growth factor-1 levels went down by 30 percent. These changes held over several dietary cycles.

I was concerned about body weight, but the weight loss appeared reversible during the healthy-eating periods between fasting cycles.

That’s a brief overview of this very recent study. It is only in abstract form, but I wanted to share it with you now. I love that the fasting-mimicking diet had a broad and favorable effect on immune system function. The diet approach led to many anti-cancer programs in the cancer cells.

I have recently been thinking more about out-of-the-box approaches for my patients at high risk for cancer-related recurrence or death. I am especially interested in approaches that modulate insulin-like growth factor-1 (IGF-1).

In summary, the new study reveals that a fasting-mimicking diet is associated with a significant rise in tumor-infiltrating CD8-positive T cells. This diet leads to an anti-cancer immune microenvironment at cancer cell and systemic levels.

Let’s close with the words of research team member Licia Rivoltini, MD, head of the immunotherapy of human tumors unit at the National Cancer Institute in Milan:

“Severe calorie restriction generated a metabolic shock that activated several populations of immune cells that could boost the antitumor activity of standard antineoplastic treatments.”

I look forward to seeing results from new clinical research, including the BREAKFAST trial. This experiment is the next step in understanding the anti-cancer effects caused by calorie restriction.

Oh, I cannot resist this shot of me in fabulous Milan:

Thank you for joining me today. I hope you have a joy-filled next year.

The post Fasting May Fight Cancer appeared first on Medika Life.

If your only takeaway from this article is the following, the it has served its purpose.

Chemo is not a cure for cancer. It is not a magic bullet that can be used to rid your body of cancer. Do not rely on it for that purpose, Chemo is simply a tool in the fight against cancer, a treatment that is occasionally met with some success.

Worth noting is that this article relates only to chemo in terms of cancer treatment and not antimicrobial chemotherapy.

This article is over 25 minutes long and if there are certain sections that are not of interest, the list below will help you navigate the article.

Article Contents

1. The origins of Chemotherapy

Not unsurprisingly perhaps, this treatment traces it’s routes back to World War I and the German introduction of chemical warfare. Among the chemical agents used, mustard gas was particularly devastating. Although banned by the Geneva Protocol in 1925, the advent of World War II caused concerns over the possible re-introduction of chemical warfare. Such concerns led to the discovery of nitrogen mustard, a chemical warfare agent, as an effective treatment for cancer.

Two pharmacologists from the Yale School of Medicine, Louis S. Goodman and Alfred Gilman, were recruited by the US Department of Defense to investigate the potential therapeutic applications of chemical warfare agents.

(Authors note — there is so much wrong with the sentence above that reading it now raises a smile. It is, however, the official explanation given by the DOD and we’ll leave it there)

Goodman and Gilman observed that mustard gas was too volatile and they subsequently developed a more stable compound called nitrogen mustard. A year into the start of their research, a German air raid in Bari, Italy led to the exposure of more than 1000 people to the SS John Harvey’s* secret cargo of mustard gas bombs.

• read the unlikely story behind the SS John Harvey in the footer

Dr. Stewart Francis Alexander, a lieutenant colonel who was an expert in chemical warfare, was subsequently deployed to investigate the aftermath. Autopsies of the victims suggested that profound lymphoid and myeloid suppression had occurred after exposure. In his report, Dr. Alexander theorized that since mustard gas all but ceased the division of certain types of somatic cells whose nature is to divide rapidly, it could also potentially be put to use in helping to suppress the division of certain types of cancerous cells.

Goodman and Gilman reasoned that this agent could be used to treat lymphoma, a tumor of lymphoid cells. In collaboration with a thoracic surgeon, Gustaf Lindskog, they injected a related agent, mustine (the prototype nitrogen mustard anticancer chemotherapeutic), into a patient with non-Hodgkin’s lymphoma. A dramatic reduction in the patient’s tumor masses were observed but the effect lasted only a few weeks, and the patient had to return for another set of treatment, This was, in effect the first step to the realization that cancer could be treated by pharmacological agents.

Publication of the first clinical trials was reported in 1946 in the New York Times and chemotherapy was born.

2. How does chemo work?

Chemotherapy is considered a systemic therapy as drugs are introduced into the blood stream and are therefore, in principle, able to address cancer at any anatomic location in the body. Systemic therapy is often used in conjunction with other local therapies (i.e. treatments whose efficacy is confined to the anatomic area where they are applied) for cancer such as radiation therapy, surgery or hyperthermia therapy.

Traditional chemotherapeutic agents are cytotoxic — i.e. they are toxic to our cells, effectively a poison, a natural equivalent would be snake venom which can destroy human cells — and this is they reason they are able to destroy cancer cells. However, we remain unable to fashion traditional agents to specifically target and attack only cancerous cells. Chemotherapeutic agents also destroy healthy cells and therein lies the quandary.

Scientifically we would describe chemotherapy as connoting non-specific usage of intracellular poisons to inhibit mitosis (cell division) or induce DNA damage, which is why inhibition of DNA repair can augment chemotherapy

Chemotherapy can, in its simplest form, be thought of as a way to damage or stress cells, which may then lead to cell death if apoptosis is initiated. Many of the side effects of chemotherapy can be traced to the damage of normal cells that divide rapidly and are therefor, as with cancerous cells, sensitive to anti-mitotic drugs: cells in the bone marrow, digestive tract and hair follicles.

This results in the more common side-effects of chemotherapy:

• myelosuppression (decreased production of blood cells, resulting in immunosuppression)
• mucositis (inflammation of the lining of the digestive tract)
• and alopecia (hair loss).

3. Understanding treatment protocols

Chemotherapeutics are used in two settings, curative or palliative. The first is self-explanatory, the second, palliative, relates to treatments designed to extend life expectancy, management rather than cure of the disease in question. It is a last ditch effort to buy a patient that “extra over” at the end of their innings. Sadly, the quality of this extra time is often compromised by the side effects of chemo and the real world implications of opting for late-stage palliative chemotherapy are often not adequately discussed with the recipient or family.

Combinations of drugs are used in treatment as these have proven more effective in combatting cancers. Cancerous cells have proven themselves immensely adaptive and able to deflect, adapt to and overcome the efforts of a single chemotherapeutical to destroy them, so doctors opt for combinations, determined by the type of cancer in question. There is now a growing debate in the medical community over how aggressive treatment protocols may serve to encourage cancers to metastasize.

If you’ve or a family member has been exposed to or will undergo chemo, you will hear the following terms;

• Induction chemotherapy: The first line treatment of cancer with a chemotherapeutic drug. This type of chemotherapy is used for curative intent.
• Combined modality chemotherapy: The use of drugs with other cancer treatments, such as surgery, radiation therapy, or hyperthermia therapy.
• Consolidation chemotherapy: Given after remission in order to prolong the overall disease-free time and improve overall survival. The drug that is administered is the same as the drug that achieved remission.
• Intensification chemotherapy: Identical to consolidation chemotherapy but a different drug than the induction chemotherapy is used.
• Combination chemotherapy: Thisinvolves treating a person with a number of different drugs simultaneously. The drugs differ in their mechanism and side-effects. The biggest advantage is minimizing the chances o;f resistance developing to any one agent. Also, the drugs can often be used at lower doses, reducing toxicity.
• Neoadjuvant chemotherapy: This is given prior to a local treatment such as surgery, and is designed to shrink the primary tumor. It is also given for cancers with a high risk of micrometastatic disease.
• Adjuvant chemotherapy: Given after a local treatment (radiotherapy or surgery). It can be used when there is little evidence of cancer present, but there is risk of recurrence. It is also useful in killing any cancerous cells that have spread to other parts of the body. These micrometastases can be treated with adjuvant chemotherapy and can reduce relapse rates caused by these disseminated cells.
• Maintenance chemotherapy: A repeated low-dose treatment to prolong remission.
• Salvage chemotherapy: Palliative chemotherapy is given without curative intent, but simply to decrease tumor load and increase life expectancy. For these regimens, in general, a better toxicity profile is expected.

4. Types of Chemotherapeutics

This section if included for the more technically mined. Page down to carry on reading issues relating to dosing and the side effects of chemotherapy.

Alkylating agents

Alkylating agents are the oldest group of chemotherapeutics in use today. Originally derived from mustard gas used in World War I, there are now many types of alkylating agents in use. They are so named because of their ability to alkylate many molecules, including proteins, RNA and DNA. This ability to bind covalently to DNA via their alkyl group is the primary cause for their anti-cancer effects. Read more…

Antimetabolites

Anti-metabolites are a group of molecules that impede DNA and RNA synthesis. Many of them have a similar structure to the building blocks of DNA and RNA. These drugs exert their effect by either blocking the enzymes required for DNA synthesis or becoming incorporated into DNA or RNA. By inhibiting the enzymes involved in DNA synthesis, they prevent mitosis because the DNA cannot duplicate itself. Read more…

Anti-microtubule agents

Anti-microtubule agents are plant-derived chemicals that block cell division by preventing microtubule function. Microtubules are an important cellular structure composed of two proteins, α-tubulin and β-tubulin. They are hollow, rod-shaped structures that are required for cell division, among other cellular functions. Read more…

Topoisomerase inhibitors

Topoisomerase inhibitors are drugs that affect the activity of two enzymes: topoisomerase I and topoisomerase II. When the DNA double-strand helix is unwound, during DNA replication or transcription, for example, the adjacent unopened DNA winds tighter (supercoils), like opening the middle of a twisted rope. The stress caused by this effect is in part aided by the topoisomerase enzymes. Read more…

Cytotoxic antibiotics

The cytotoxic antibiotics are a varied group of drugs that have various mechanisms of action. The common theme that they share in their chemotherapy indication is that they interrupt cell division. The most important subgroup is the anthracyclines and the bleomycins; other prominent examples include mitomycin C and actinomycin. Read more…

5. Dosages and outdated systems

Chemotherapeutical dosage strengths are critical to ensure optimal treatment. Too little and the cancer will continue to grow, to much and the treatment can kill the patient.. It’s a delicate balance and strengths of dosage are determined by an archaic system that ignores various factors, considering only the height and weight of the patient. It is called the BSA or body surface area. The BSA is usually calculated with a mathematical formula or a nomogram, using the recipient’s weight and height, rather than by direct measurement of body area.

The BSA formula was originally developed in a 1916 study and attempted to translate medicinal doses established with laboratory animals to equivalent doses for humans and only included nine human subjects. When chemotherapy was introduced in the 1950s, the BSA formula was adopted as the official standard for chemotherapy dosing for lack of a better option.

Drug absorption and clearance are influenced by multiple factors, including age, sex, metabolism, disease state, organ function, drug-to-drug interactions, genetics, and obesity, which have major impacts on the actual concentration of the drug in the person’s bloodstream. There is high variability in the systemic chemotherapy drug concentration in people dosed by BSA, and this variability has been demonstrated to be more than ten-fold for many drugs

To explain this properly, in two individuals of identical body weight given identical dosages using BSA, concentrations of the drug can be up to ten times higher in one individual than the other. Both patients are at risk, one from under dosage and the other from the potential of being fatally poisoned. Clearly, BSA is not fit for purpose.

In a randomized clinical trial, investigators found 85% of metastatic colorectal cancer patients treated with 5-fluorouracil (5-FU) did not receive the optimal therapeutic dose when dosed by the BSA standard — 68% were under dosed and 17% were overdosed. The problem is exacerbated by rising rates of obesity. We need to do far better to ensure optimal treatment.

Several clinical studies have demonstrated that when chemotherapy dosing is individualized to achieve optimal systemic drug exposure, treatment outcomes are improved and toxic side effects are reduced. In the 5-FU clinical study cited above, people whose dose was adjusted to achieve a pre-determined target exposure realized an 84% improvement in treatment response rate and a six-month improvement in overall survival (OS) compared with those dosed by BSA.

6. The Side Effects of Chemo

Chemotherapeutic techniques have a broad range of well documented side-effects. These side-effects depend largely on the type of medications used in treatment. The most common medications affect mainly the fast-dividing cells of the body, such as blood cells and the cells lining the mouth, stomach, and intestines. Toxicities can occur acutely after administration, within hours or days, or chronically, from weeks to years. As discussed above, correct dosage strengths for treatments are perhaps the best tool to prevent or reduce these side effects.

Immunosuppression and myelosuppression

Virtually all chemotherapeutic regimens can cause depression of the immune system, often by paralysing the bone marrow and leading to a decrease of white blood cells, red blood cells, and platelets. Anemia and thrombocytopenia may require blood transfusion.

In very severe myelosuppression, which occurs in some regimens, almost all the bone marrow stem cells (cells that produce white and red blood cells) are destroyed, meaning allogenic or autologous bone marrow cell transplants are necessary. In some instances treatment has to be halted as immune suppression poses serious risk to the patients life.

Although people receiving chemotherapy are encouraged to wash their hands, avoid sick people, and take other infection-reducing steps, about 85% of infections are due to naturally occurring microorganisms in the person’s own gastrointestinal tract (including the mouth) and skin. The risk of illness and death can be reduced by taking common antibiotics such as quinolones or trimethoprim/sulfamethoxazole before any fever or sign of infection appears. Quinolones show effective prophylaxis mainly with hematological cancer.

In Japan, the government has approved the use of some medicinal mushrooms like Trametes versicolor, to counteract depression of the immune system in people undergoing chemotherapy.

Neutropenic enterocolitis

Due to immune system suppression, neutropenic enterocolitis (typhlitis) is a “life-threatening gastrointestinal complication of chemotherapy”. Typhlitis is an intestinal infection which may manifest itself through symptoms including nausea, vomiting, diarrhea, a distended abdomen, fever, chills, or abdominal pain and tenderness. Typhlitis is a medical emergency. It has a very poor prognosis and is often fatal unless promptly recognized and aggressively treated.

Gastrointestinal distress

Nausea, vomiting, anorexia, diarrhoea, abdominal cramps, and constipation are common side-effects of chemotherapeutic medications that kill fast-dividing cells. Malnutrition and dehydration can result when the recipient does not eat or drink enough, or when the person vomits frequently, because of gastrointestinal damage. This can result in rapid weight loss, or occasionally in weight gain, if the person eats too much in an effort to allay nausea or heartburn. Weight gain can also be caused by some steroid medications. These side-effects can frequently be reduced or eliminated with antiemetic drugs.

Anemia

Anemia can be a combined outcome caused by myelosuppressive chemotherapy, and possible cancer-related causes such as bleeding, blood cell destruction (hemolysis), hereditary disease, kidney dysfunction, nutritional deficiencies or anemia of chronic disease. Treatments to mitigate anemia include hormones to boost blood production (erythropoietin), iron supplements, and blood transfusions.

Nausea and vomiting

Nausea and vomiting are two of the most known and feared cancer treatment-related side-effects. In 1983, Coates et al. found that people receiving chemotherapy ranked nausea and vomiting as the first and second most severe side-effects, respectively. Up to 20% of people receiving highly emetogenic agents in this era postponed, or even refused, potentially curative treatments.

Chemotherapy-induced nausea and vomiting (CINV) are common with many treatments and some forms of cancer. Since the 1990s, several novel classes of antiemetics have been developed and commercialized, becoming a nearly universal standard in chemotherapy regimens, and helping to successfully manage these symptoms in many people. Ensuring accurate levels of dosage also greatly reduce these side-effects. Read more…

Hair loss

Hair loss (alopecia) can be caused by chemotherapy that kills rapidly dividing cells; other medications may cause hair to thin. These are most often temporary effects: hair usually starts to regrow a few weeks after the last treatment, but sometimes with a change in color, texture, thickness or style. Sometimes hair has a tendency to curl after regrowth, resulting in “chemo curls.” Severe hair loss occurs most often with drugs such as doxorubicin, daunorubicin, paclitaxel, docetaxel, cyclophosphamide, ifosfamide and etoposide. Permanent thinning or hair loss can result from some standard chemotherapy regimens.

Secondary neoplasm

Development of secondary neoplasia after successful chemotherapy or radiotherapy treatment can occur. The most common secondary neoplasm is secondary acute myeloid leukemia, which develops primarily after treatment with alkylating agents or topoisomerase inhibitors. Survivors of childhood cancer are more than 13 times as likely to get a secondary neoplasm during the 30 years after treatment than the general population, however not all of this increase can be attributed to chemotherapy.

Infertility

Some types of chemotherapy are gonadotoxic and may cause infertility. Chemotherapies with high risk include procarbazine and other alkylating drugs such as cyclophosphamide, ifosfamide, busulfan, melphalan, chlorambucil, and chlormethine. Drugs with medium risk include doxorubicin and platinum analogs such as cisplatin and carboplatin.

Female infertility by chemotherapy appears to be secondary to premature ovarian failure by loss of primordial follicles. This loss is not necessarily a direct effect of the chemotherapeutic agents, but could be due to an increased rate of growth initiation to replace damaged developing follicles. People can choose between several methods of fertility preservation prior to chemo, including cryopreservation of semen, ovarian tissue, oocytes, or embryos.

Teratogenicity

Chemotherapy is teratogenic ( an agent that can disturb the development of the embryo or fetus) during pregnancy, especially during the first trimester, to the extent that abortion usually is recommended if pregnancy in this period is found during chemotherapy. Second- and third-trimester exposure does not usually increase the teratogenic risk and adverse effects on cognitive development, but it may increase the risk of various complications of pregnancy and fetal myelosuppression.

In males previously having undergone chemotherapy or radiotherapy, there appears to be no increase in genetic defects or congenital malformations in their children conceived after therapy. In females previously having undergone chemotherapy, miscarriage and congenital malformations are not increased in subsequent conceptions. However, when in vitro fertilization and embryo cryopreservation is practised between or shortly after treatment, possible genetic risks to the growing oocytes exist, and it is recommended that the babies be screened.

Peripheral neuropathy

Between 30 and 40 percent of people undergoing chemotherapy experience chemotherapy-induced peripheral neuropathy (CIPN), a progressive, enduring, and often irreversible condition, causing pain, tingling, numbness and sensitivity to cold, beginning in the hands and feet and sometimes progressing to the arms and legs. Read more…

Cognitive impairment

Some people receiving chemotherapy report fatigue or non-specific neurocognitive problems, such as an inability to concentrate; this is sometimes called post-chemotherapy cognitive impairment, referred to as “chemo brain” in popular and social media.

Tumor lysis syndrome

Large tumors and cancers with high white cell counts, such as lymphomas, teratomas, and some leukemias, can lead to some people develop tumor lysis syndrome. The rapid breakdown of cancer cells causes the release of chemicals from the inside of the cells. Following this, high levels of uric acid, potassium and phosphate are found in the blood. High levels of phosphate induce secondary hypoparathyroidism, resulting in low levels of calcium in the blood. This causes kidney damage and the high levels of potassium can cause cardiac arrhythmia. Potentially fatal if untreated.

Organ damage

Cardiotoxicity (heart damage) is especially prominent with the use of anthracycline drugs (doxorubicin, epirubicin, idarubicin, and liposomal doxorubicin).

Hepatotoxicity (liver damage) can be caused by many cytotoxic drugs. The susceptibility of an individual to liver damage can be altered by other factors such as the cancer itself, viral hepatitis, immunosuppression and nutritional deficiency. The liver damage can consist of damage to liver cells, hepatic sinusoidal syndrome (obstruction of the veins in the liver), cholestasis (where bile does not flow from the liver to the intestine) and liver fibrosis.

Nephrotoxicity (kidney damage) can be caused by tumor lysis syndrome and also due direct effects of drug clearance by the kidneys. Different drugs will affect different parts of the kidney and the toxicity may be asymptomatic (only seen on blood or urine tests) or may cause acute kidney injury.

Ototoxicity (damage to the inner ear) is a common side effect of platinum based drugs that can produce symptoms such as dizziness and vertigo. Children treated with platinum analogues have been found to be at risk for developing hearing loss.

Other side-effects

Less common side-effects include red skin (erythema), dry skin, damaged fingernails, a dry mouth (xerostomia), water retention, and sexual impotence. Some medications can trigger allergic or pseudoallergic reactions.

Specific chemotherapeutic agents are associated with organ-specific toxicities, including cardiovascular disease (e.g., doxorubicin), interstitial lung disease (e.g., bleomycin) and occasionally secondary neoplasm (e.g., MOPP therapy for Hodgkin’s disease).

Hand-foot syndrome is another side effect to cytotoxic chemotherapy.

7. What do the outcomes look like for chemo patients?

Not brilliant, and this has as much to do with dosing as with the nature of the treatments themselves. Getting the dosage right and hitting that sweet spot of balancing the efficacy of the attack on the cancer against the toxicity experienced by the patient matters hugely. Because of the reduced toxicity, dose-adjusted patients in the 5-FU trial referenced above were able to be treated for longer periods of time. BSA-dosed people were treated for a total of 680 months while people in the dose-adjusted group were treated for a total of 791 months.

Similar results were found in a study involving people with colorectal cancer who were treated with the popular FOLFOX regimen. The incidence of serious diarrhea was reduced from 12% in the BSA-dosed group of patients to 1.7% in the dose-adjusted group, and the incidence of severe mucositis was reduced from 15% to 0.8%.

Chemo is not a cure for cancer, it is a treatment. Expectations for patients receiving chemo present an issue. Chemotherapy does not always work, and even when it is useful, it may not completely destroy the cancer. People frequently fail to understand its limitations. In one study of people who had been newly diagnosed with incurable, stage 4 cancer, more than two-thirds of people with lung cancer and more than four-fifths of people with colorectal cancer still believed that chemotherapy was likely to cure their cancer.

Fault can be laid squarely at the door of the healthcare profession in this instance, with lack of proper educational materials and poor or absent doctor patient interaction. What the medical profession view as success within the narrow scope of chemotherapeutics and what the public perceive are worlds apart. Success can translate to extending life expectancy by two months or remission. It is the duty of the caregiver to ensure that expectations are shared and understood and that both parties are mutually aware of desired outcomes.

If your doctor or healthcare provider does not offer you total transparency in terms of the above along with access to relevant information pertaining to you your treatment, seek alternate advice.

Despite all the side effects, many of which are life threatening, chemo does still have its place in the medical arsenal against cancer and there are success stories of ‘successful’ outcomes for patients, whether that be extension of life or remission. It is however critical that your doctor evaluates your cancer against all the potential treatments available and assess you correctly in terms of chemo as an appropriate treatment.

8. What are the alternatives to chemo?

Chemotherapeutical’s suffer two basic and telling shortcomings that lead to far from ideal outcomes. They are, at the end of the day, a toxin and toxins are not well tolerated. Their biggest issue however is the lack of cell specificity of the drugs. They cannot distinguish between healthy cells and cancerous cells.

Certain cancers will respond to treatment from chemo whilst others simply shrug off the drugs and acquired resistances renders drugs useless. Newer drugs however, work in a far more targeted fashion that hugely reduce many of the serious side effects associated with chemo treatment.

Targeted Therapies

Targeted therapies are a relatively new class of cancer drugs that can overcome many of the issues seen with the use of cytotoxics. They are divided into two groups: small molecule and antibodies. The massive toxicity seen with the use of cytotoxics is due to the lack of cell specificity of the drugs. They will kill any rapidly dividing cell, tumor or normal. Targeted therapies are designed to affect cellular proteins or processes that are utilized by the cancer cells.

This allows a high dose to cancer tissues with a relatively low dose to other tissues. Although the side effects are often less severe than that seen of cytotoxic chemotherapeutics, life-threatening effects can still occur. Initially, targeted therapeutics were designed to be solely selective for one protein.

Now it is clear that there is often a range of protein targets that the drug can bind. An example for targeted therapy is the BCR-ABL1 protein produced from the Philadelphia chromosome, a genetic lesion found commonly in chronic myelogenous leukemia and in some patients with acute lymphoblastic leukemia. This fusion protein has enzyme activity that can be inhibited by imatinib, a small molecule drug.

Steroids

Steroids are drugs that act like your body’s own hormones. They can help treat many types of cancer, and they can keep you from having nausea and vomiting after a round of chemo. They can also prevent allergic reactions to other drugs. They are not however without risk of their own and prolonged use has been linked to an increased risk of developing nonmelanoma-type skin malignancies and non-Hodgkin’s lymphoma.

Typical steroids prescribed for cancer inlude;

• prednisolone
• methylprednisolone
• dexamethasone
• hydrocortisone

Depending on the type of cancer, it is well worth exploring steroids as an alternative form of treatment. You can learn more about the topic by following this link.

Clinical Trials

There a continuous raft of clinical trials for cancer treatments and you can find an exhaustive list of these on the Cancer.org website for American patients. These can often provide an alternative to individuals who are not comfortable with the option of chemo as a treatment and whose cancer may not lend itself to any of the treatments mentioned above.

Follow the link below to keep updated on trials as they become available and discuss this option with your doctor if you feel a trial may offer you a better outcome.Clinical Trials Information for Patients and CaregiversClinical trials are research studies that involve people. Any time you or a loved one need treatment for cancer…www.cancer.gov

9. The financial incentive for chemo treatment

I’ve left the controversy for last and it is a topic most doctors skirt around, but it is an important issue to address as it helps one to understand the dynamics at play and the eagerness to enroll patients for chemo.

Brand-name chemotherapy is often incredibly expensive, in excess of $100,000 per patient.

Healthcare requires funding to keep its doors open. This is true for a small private practice and applies equally to large hospitals and clinics. Pharmaceutical companies incentivize the sale of their chemotherapeutics to ensure their profitability. Incentives are financial in nature and benefit the prescribing individual or organization. As chemo treatments can last over extensive periods of time and the drugs are costly, the returns can generate a solid revenue stream.

Oncologists were placed in the spotlight by the NYT as early as 2003.

Cancer specialists (oncologists) are pocketing hundreds of millions of dollars each year by selling drugs to patients — a practice that almost no other doctors follow.

The practice of purchasing drugs directly from pharmaceutical companies, often at hugely discounted prices to administer to your patients in the setting of your practice is unique to Oncology and creates an environment for ethical abuse, a potential conflict of interest for these doctors, who must help patients decide whether to undergo or continue chemotherapy if it is not proving to be effective, and which drugs to use.

Another study raised this issue. The cost of cancer care continues to increase at an unprecedented rate. Concerns have been raised about financial incentives associated with the chemotherapy concession in oncology practices and their impact on treatment recommendations.

Oncologists receive a 6% markup, meaning when they infuse a patient with a branded $10,000 monthly course of chemotherapy, their practice yields an extra $600. This reduces the desire to prescribe cheaper generics and places additional stress on insurers, who are actively trying to restrict the profits of oncologists. Last month, in August, Forbes ran an article on the topic.

Finally, in an aptly entitled piece from 2019, ny StaffNews, The Cancer in Cancer Medicine; pharma money paid to doctors

If anything gives you pause for thought when your are prescribed chemo, this one single aspect should be at the forefront of your mind. It is a sad reflection on the medical profession that at a point in the patients life, when they are most in need of unbiased, caring, patient focused treatment, they need to be watching their backs — and their wallets.

As promised, we’re at the end and the story below is of little relevance, but of historical interest in the development of chemotherapeutics.

The SS John Henry

In August 1943, Roosevelt approved the shipment of chemical munitions containing mustard agent to the Mediterranean theater. On 18 November 1943 the John Harvey, commanded by Captain Elwin F. Knowles, sailed from Oran, Algeria, to Italy, carrying 2,000 M47A1 mustard gas bombs, each of which held 60–70 lb of sulfur mustard, in clear contravention of the Geneva Convention. After stopping for an inspection by an officer of the 7th Chemical Ordnance Company at Augusta, Sicily on 26 November, the John Harvey sailed through the Strait of Otranto to arrive at Bari.

Bari was packed with ships waiting to be unloaded, and the John Harvey had to wait for several days. Captain Knowles wanted to tell the British port commander about his deadly cargo and request it be unloaded as soon as possible, but secrecy prevented him doing so. (Again the official version. Transporting chemical weapons was a punishable offence under the Geneva Convention)

On 2 December 1943 German aircraft attacked Bari, killing over 1,000 people, and sinking 28 ships, including the John Harvey, which was destroyed in a huge explosion, causing liquid sulfur mustard to spill into the water, mixing with oil from the sunken ships, and a cloud of sulfur mustard vapor to blow over the city. Nearly all crewmen of John Harvey perished in the sinking, this prevented the rescuers from knowing the real nature of the danger until a M47A1 bomb fragment was retrieved from the wreckage.

A total of 628 military victims were hospitalized with mustard gas symptoms, and by the end of the month, 83 of them had died. The number of civilian casualties, thought to have been even greater, could not be accurately gauged since most had left the city to seek shelter with relatives.

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