Why Standard Cancer Treatments Fail (And How to Fight Back)

Transcript of Dr. Dawn Lemanne on Kicking Cancer's Ass

Dawn Lemanne, MD: Breast cancer, lung cancer, colon cancer pancreatic cancer have not been cured despite decades of large, randomized controlled trials.

We can have two people with the identical mutations within their cancer, and they may respond differently to the same treatment because there are so many other variables that come into play and are active in a cancer situation.

We need to know in real time whether this treatment with its toxicities is actually doing anything beneficial.

We will have patches on the arm that are like continuous glucose monitors that be continuous tumor monitors.

Is it possible that we could maybe try to deal with resistance before it happens rather than expecting it to happen and doing everything we know that will cause resistance .

I haven't met anyone who doesn't like to feel like after a terrible diagnosis, like a cancer diagnosis where your life is threatened, having some more control is generally something that people thrive with and look forward to.

I wake up every day thinking I'm so lucky that I get to be a doctor. 

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Joelle Kaufman: What if everything we know about late stage cancer treatment is backwards? While standard Oncology accepts treatment resistance as inevitable for metastatic disease, something to manage until the disease kills you, Dr. Dawn Lemanne is proving it can be reversed. Dr. Lemanne, it is such a pleasure to have you on kicking cancer's ass.

Dawn Lemanne, MD: Yes. Thank you for having me.

Joelle Kaufman: right, so let's dive in. You work with patients who've often been told their metastatic cancer is incurable. When someone walks into your office carrying that prognosis, do you shift the conversation from managing inevitable resistance to let's see if we can reverse what everyone says is irreversible.

Dawn Lemanne, MD: I think oncologists don't ask the question, why can't we reverse treatment resistance? I have been trying to think about that question and that's how I ran into the idea of cancer as an evolutionary process.

And evolution can sometimes be steered, not always, but sometimes it can be. And where we've learned about that is from agriculture, where it's been known for decades and been used for decades. The idea that you cannot apply, for instance, a pesticide or an insecticide at maximum dose constantly and not have to deal with the development of resistance.

Is it possible that we could maybe try to deal with resistance before it happens rather than expecting it to happen and doing everything we know that will cause resistance and, maybe we should change that conversation. Everybody has to have a different conversation because they come to me and at different points in the resistance development, spectrum.

Joelle Kaufman: I would think for someone who's been told they have stage four that's metastatic, but I am really curious where does one start with reversing or avoiding inevitable resistance?

Dawn Lemanne, MD: You start where you're at. So if you're already, uh, in a resistant state, there are things that we can do to, you know, we can test your tumor, for instance, we can take a biopsy of the tumor and see if there are unusual or off the usual recipe or protocol drugs that your tumor might still be sensitive to.

That's not often done in standard therapy and the tests are not perfect. They're problematic in some ways, but at least they're, in my opinion, better than going to the list of drugs that have worked sometimes for a few people.

And we're usually talking about a very few, we're talking about the single digit percentiles in terms of, uh, treatment efficacy for, for advanced cancer. So rather than doing that, we actually interrogate the tumor. If we can, if the, if a biopsy is safe, if there's an accessible site, if there's enough tissue for a live tissue biopsy, and, uh, we will test that live tumor against various drugs and combinations of drugs even.

And this is really quite heretical, but I have a colleague who will test these, uh, tumors against all sorts of normal chemotherapy drugs, cisplatin, Taxol, those kinds of things. And also against things like. A Metformin analog or ivermectin. And by the way, most tumors are not sensitive to Ivermectin, but every now and then there is one.

You mentioned a patient with prostate cancer and frequently it usually is treated by blocking the male hormone until that treatment stops working, and again, it's expected that the treatment will stop working. My Moffitt colleagues and I, we've written a paper, we're hoping to publish it on reversing androgen deprivation therapy resistance by giving testosterone to patient, a patient with prostate cancer.

That rescues some of the cells in the tumor that are sensitive to. Testosterone and allows them to repopulate the tumor. They actually are a little bit stronger than their treatment resistant brethren, because if you're a cancer cell, maintaining treatment, resistance is a burden. Like carrying an umbrella.

People who are not having to carry an umbrella in a foot race will win.

Moffitt Cancer Center is pioneering efforts in prostate cancer. They have some very brilliant theoreticians there who are working very hard to prevent and reverse treatment resistance. So I'm just fortunate to, to be able to tag along with some of my patients.

Joelle Kaufman: So it's really interesting 'cause there's a lot of work happening in the breast cancer world as well about anti progestins. We been maybe going down a path with estrogen deprivation that is also not necessarily ideal.

Dawn Lemanne, MD: Exactly. Yeah.

Joelle Kaufman: testosterone deprivation would also be not ideal. And I think you had said you've seen the adding testosterone work, like it's not just theoretical, you've seen it

Dawn Lemanne, MD: Oh yes. This paper that we're publishing is a case where we've reversed resistance to androgen deprivation therapy, cutting off the testosterone in a patient whose prostate cancer had become resistant to that therapy, and the next step is usually really powerful chemotherapies and things like that.

We were able to move him back along the time spectrum to a place where his tumor was still sensitive. To the usual treatments and then we pulse those treatments rather than giving them constantly .

We actually use the patient's tumor dynamics. In other words, how fast the tumor grows if we withdraw treatment and how quickly it shrinks when we reapply treatment, we use that to develop dosing. Timing frameworks that maximally prevent resistance. We've also worked with breast cancer patients, um, uh, in an analogous way.

Of course breast cancer is related to female hormones, not male hormones. We've worked with patients giving female hormones in breaks from anti female hormone therapy to toggle and manage the side effects from hormone deprivation, which are quite severe.

That relieves a lot of the side effects and prolongs the sensitivity of the disease to treatment so that these patients have very long lives and very active non-symptomatic lives.

Joelle Kaufman: I know I was gonna ask this towards the end, but it just has to be asked now, how are you able to tell the dynamics of a tumor?

Dawn Lemanne, MD: One of the most exciting, I think most oncologists now are using, blood tests, liquid biopsies, circulating tumor DNA. Not circulating tumor cells, but just the DNA, the nucleotides, uh, and nucleic acids from tumor cells in the body.

We can use those to estimate the tumor burden, which is what we call the amount of cancer in a patient's body. And that number from a blood test, as tumors live and grow and die and replace themselves within your body, it's a dynamic process. We can measure whether that process is leading to tumor cell accumulation or tumor cell depletion by whether that number in your blood test of circulating tumor DNA is going up or down, and we can see how fast it's occurring as well by how fast it goes up or down. So I will use those tests, once a month if I can. And I think one of the things that, that really got me thinking about this was the frustration that I and my patients and my colleagues felt at not knowing whether a treatment that we were offering, a patient was doing anything for them. And the only way we would know, for instance, if a patient had benefit from what we call adjuvant or postoperative breast cancer therapy, for instance, was to give it to them whole course, four, six months, something like that, and then wait and do a scan, every three, six, 12 months to see if the cancer came back, and that was the only way we could answer that question. I thought, that's just not okay. We need to know in real time whether this treatment with its toxicities is actually doing anything beneficial.

So prostate cancer cells make something called prostate specific antigen, or PSA. Usually not all of them, but most of them. And we can measure that in the blood. And if the number's going up, it means the cancer's growing. If it's going down, it means it's shrinking. And so that's one that's very nice to use.

And that's one of the reasons why prostate cancer has been studied first using this particular paradigm because there is a way to measure in real time how the patients are doing breast cancers. Not as much. So about a third of breast cancers will make a tumor marker. You've heard of these CA 15 three or CA 27 29 more rarely.

CEA or CA 1 25, although those tend to be related more to gastrointestinal or gynecologic tumors respectively. But if the patient has breast cancer and that breast cancer makes one of the tumor markers, then we can measure the tumor marker as it goes up and down. Off and on treatment respectively.

So those are the tools that are used for mathematical modeling. To have that particular approach, we do have to have that kind of a tool available for that patient. But with circulating tumor, DNA, it's becoming more and more available for almost everyone.

Joelle Kaufman: So one of my, actually my very first guest was Dr. Peter Kuhn down at USC, one of the leaders in liquid Biopsy, and looking at, tumor cells as well as what they call Oncotypes. It's very exciting where things are going with blood tests. I remember you using talking about continuous glucose monitoring for something as well

Dawn Lemanne, MD: so continuous glucose monitoring has, is really separate from what we've just been discussing. So a lot of patients with cancer have metabolic derangement in their ability to use and process glucose to make energy. Tumors often will be very enamored of using glucose for energy.

So if the patient's blood glucose is a little too high, or if it spikes after each meal, even if it's normal in between, that can set the tumor up to grow faster. So using a continuous glucose monitor, we can see throughout the day how a particular meal, how a particular activity, how much sleep or sleep loss will affect the glucose levels in the body in real time. That's really important for patients who have problems with high blood sugar or even diabetes or pre-diabetes, because if you just look at a list of food out of a textbook or a magazine article or even that your doctor's office gives you, eat this, don't eat that.

That is only correct for large groups of people. On average. I would argue everyone is not average you are going to get different results with various foods that other people perhaps got.

So there was an interesting study done about 10 years ago showed that one particular pair had the exact opposite response to each food.

So in one pair, the first person when they ate a banana, their blood sugar was just perfect. When they ate a cookie, the blood sugar went way up. The other person was the opposite. When they ate the banana, their blood sugar went way up. When they ate the cookie, nothing happened. So you know, which list of foods are you going to give those two subjects in that trial.

So really, you have to look at your own blood sugar profile to know how your body responds to particular foods, meals, combinations, schedules, and it will change. Do that's a powerful tool that people who have those kinds of issues and have tumors that are sensitive to glucose can use and that's where CGM is very powerful.

Joelle Kaufman: Let's talk about your n equals one research, your single patient trials, which, seems to go against a lot of what we consider the gold standard, large double blind control trials, tell us more about why you believe that the n equals one is how you do it and why you think that is where the future of medicine's gonna go.

Dawn Lemanne, MD: I certainly think it's the future of oncology. And the reason I think that is because simply large, randomized controlled trials have failed in oncology completely over the past 40 or 50 years. Four or five decades of large randomized controlled trials in the common. Cancers of adulthood in the metastatic stage.

Okay? I'm not talking about stages one, two, or three, but I'm talking about in the metastatic stage. Breast cancer, lung cancer, colon cancer pancreatic cancer those kinds of and a few others. Those kinds of cancers have not been cured despite decades of large, randomized controlled trials.

Completely failed. Not one. Cure. I think it's time to retire the large randomized controlled trial for many parts of cancer research.

Of course, it still has a place, but I think the place is going to be smaller. We can have two people with the identical mutations within their cancer, and they may respond differently to the same treatment because there are so many other variables that come into play and are active in a cancer situation. These are large systems. When you perturb them in one way , something else balloons out there and you squeeze over here and something balloons out there.

Joelle Kaufman: Interrogating the tumor and testing the tumor's response to different treatments and then what treatments does that tumor respond to?

Dawn Lemanne, MD: So we can take the tumor out of the patient and test it outside of the patient. Is that perfect? No. The best, test is the tumor inside of the patient. So because the inside of the patient will differ from the inside of the next patient. Yes, it's very very specific to that particular patient and to all sorts of variables that we don't think of time of day.

Time of day that they eat. How recently they've had any antibiotics because that changes the gut microbiome. How many vaccinations they've had and which ones, how recently they've had COVID or flu. Those things all readjust the body's ability to fight cancer. And we're just starting to understand that.

Joelle Kaufman: So if a patient is re-engineering how they're living their lives, or at least being much more attuned to things like, okay, you need to track your sleep, you need to think about the times you eat what the composition is and all these things beyond what's happening in your office or an infusion center.

Dawn Lemanne, MD: All of these things in my practice, we like to take a look at and adjust and optimize as best we can. And we try to measure to see whether we're meeting our goals. So one of the things that I really try to do with my patients is not just, again, give them a list of rules or suggestions, get better sleep or get some exercise or have a healthy diet, I actually measure and help them measure. They don't need me to do this, but I like to be able to have them measure and see whether they're meeting their optimal sleep goals amounts and stages and those kinds of things.

Whether their blood sugar is in a good place all day and all night. Are they actually getting enough exercise in the right kind of exercise? That's an interesting one because even very fit people who exercise a lot tend, and these are large randomized or at least observational studies, large trials, look at even athletes tend to overestimate how much they actually work out and exercise and how intense it is.

So actually seeing on your phone exactly how many steps you've taken that day how many really intense, zone five workouts you've had and how many minutes that week, how many zone two workouts, how much of that you've had really is eyeopening to people and allows them to take control over something that, didn't really had a fuzzy sense of, and really no control over.

I haven't met anyone who doesn't like to feel like after a terrible diagnosis, like a cancer diagnosis where your life is threatened, having some more control is generally something that people thrive with and look forward to.

It's it's a really empowering.

There was actually a study in Canada, the start trial that you've probably heard of I think it was finished about 10 years ago that showed that exercise actually did I? Improved survival in patients who were on chemotherapy, who exercised at a vigorous level three times a week for 40 minutes.

That was the amount in the trial, and that's a lot for people, especially if they haven't been exercising. But it actually improved survival. So those patients who did their exercise during their chemotherapy, not waiting till after they're done, but actually during their chemotherapy actually had better breast cancer specific survival, meaning that the exercise helped kill cancer cells. This is an anti-cancer medicine. Don't just go out and exercise and hope your cancer goes away. It's not going to, but if you are having treatment for cancer you can talk to your own doctors about this study and say, does this apply to me? Should I be exercising 40 minutes three times a week?

And maybe I should. And I think that's very empowering and really important for people to know. Exercise truly is medicine.

Joelle Kaufman: I just had a vision of a a very specialized Peloton exercise support group. We're gonna do a 40 minute or maybe an hour so we have time to warm up and cool down. A lot of times it's also just being connected to people, right? I was very lucky. I had been working out lifting heavy weights, doing metabolic, high intensity interval training for years before I was diagnosed and didn't stop while I was diagnosed. It's great that it helps make the chemo work better. It also can reduce side effects. We're actually, we have an episode with Dr. Jay Harness who's talking about exercise oncology. 

Dawn Lemanne, MD: People who exercise have a lower risk of cancer in the first place. If they do get cancer, they tend to survive. And if they start exercising during a treatment, if and if they weren't exercising before, they have a better outcome, a better cancer specific.

Outcome. Yes. And that's specifically about recurrence. So what that means, what is recurrence? Recurrence means that you didn't kill all the cancer cells the first time around with your treatment. It's there were still some there. So the exercise, yes. Is part of the treatment.

Joelle Kaufman: I'd love to know how you came to this work, how you chose oncology, how you chose medicine, and then how you came to this work, the work of, challenging the conventional thinking and doing this level of personalized medicine.

Dawn Lemanne, MD: Secretly am a hypochondriac and wanted to be able to, have more say in my own health. But I was interested in medicine, and cancer, from a very young age, like seven or eight. And so I also was very interested in nutrition and how lifestyle and exercise played into whether people got cancer, whether they recovered.

I have a master's degree in epidemiology. Because that was the only way when I was in college that you could study cancer and nutrition and cancer and exercise by looking at large groups. Now we have more tools and so we can look at the individual.

So one of the reasons that I've become interested in the individuals because of the maturation of some of these tools that allow us to look at the individual. So in the past I'm not faulting past medicine. Those were the tools we have. We had epidemiology. We can look at large tr groups of people where we can try to look at large groups of people.

It turns out that's not a very great lens, but we can look with those, with the tools of Epidemiology. Epidemiology. Now we can look at each person separately. I also have been very interested in large complex systems and the mathematics of large complex systems, and I'm interested in development, biological development, and cancer.

Is development gone awry? Why does an egg and a sperm united turn into a. A whole organism with many parts and organs and senses and things like that. And of course, cancer is a problem of that particular process. So those are some of the things that got me interested in this particular field.

I wake up every day thinking I'm so lucky that I get to be a doctor. That's what I've always wanted to do. Thing to get up in the morning and get to do this work.

Joelle Kaufman: There was this term you've used in the past called mathematical oncologists, which kind of sounds like something from a science fiction movie. What is mathematical oncology and how are you using math and how do you think ai, which is math on steroids. are you using math?

Dawn Lemanne, MD: I'm waiting for the math based AI models to come out. Right now we have the word based ones and they're pretty fun, but wait till the math based ones come out .

There's a department of there's an integrated mathematical oncology department at Moffitt Cancer Center, and people who are interested can go to the integrated Mathematical Oncology Department of Moffitt Cancer Center website and kind of look around there and see what they do specifically.

But basically it's using mathematics, which is the language of nature, mathematics, and nature are the same to predict treatment response and growth patterns and all sorts of parameters related to cancer growth. And shrinkage. One of the most, one of the most sexy parts of that is something called, game theory, where you can take two agents that have a particular goal and give them some simple rules and set them against each other and see who who prevails.

For instance, how that would work in oncology is, when a tumor becomes resistant to a treatment, it generally upregulates a certain pathway that will negate the effects of the treatment, either by changing the drug's chemistry or by having the cell be able to spit the drug out or by making it so that the cell does no longer takes up that drug or any kind of mechanism.

One of the things that the game theorists in the department of Mathematical Oncology or the field of that mathematical oncology try to do is figure out how to set up a series of drugs so that as the tumor becomes resistance resistant to one, it becomes sensitive to the next treatment that's going to be applied.

So that's a double bind. So yeah, tumor cell, you might go ahead and figure out how to make your cell surface not fit this drug, number one. But if you change it in a way so that it then fits number two, then we're coming in with number two and we try to engineer that. That's one kind of approach. One of the things that we do with, say, prostate cancer is look at how fast the tumor goes up. The PSA goes up and how fast it comes down with a particular treatment, and we try to, instead of making the PSA go down.

We didn't figure this out, except by watching what the tumors do it turns out that if you just make the PSA go down a little bit, like maybe 50% and kind of keep it between 25 and 75% you can make the sensitivity last a long time. And you do that by withdrawing and reapplying the treatment as needed to keep the PSA within those parameters.

And one of the things that we're taught in in, in classical cancer school is, get that tumor marker down as far as you possibly can. It turns out that's the worst thing you could do in if you want to create resistance, that's how you do it. And we were taught that no, if you want to prevent resistance, you get that tumor marker down as long as you can and you keep hammering with that same drug. And what we would see is that even when we did that, the tumor would eventually escape and come back up, even though we were still hammering with the drug. That's another place where mathematical oncology has been helpful.

There are in silico models that mathematicians can make of tumor growth. And then they can test two or three parameters. Some of the people doing this at Moffitt have found, for instance, that applying certain drugs at certain points in a tumor's growth cycle like Bevacizumab which is an anti-angiogenesis agent, can actually make the tumors more aggressive or they can prevent because they block the production of blood vessels. If you give that first and the tumor's blood vessels shrink away, then you give some chemo. The chemo can't get to the tumor. So the chemo's been rendered ineffective. So all of those things were discovered and thought about and tested in animal models first tested in silico, looking at, computer screens and what's gonna happen with this tested in animal models.

The types of mathematics that can be used to inform cancer treatment and also to give us more understanding of how cancers act and grow in a three-dimensional system.

Joelle Kaufman: So I can imagine a future where, a patient's getting treatment and blood's being tested, maybe they're scanning, but the actual infusion is being almost controlled by computer and changing based on what these models predict and then seeing how the tumor responds in the body. 

Dawn Lemanne, MD: Yes.

Joelle Kaufman: Dr. Esserman says, all that matters is if it responds to treatment and you happen to have a pathology that we think is gonna be very responsive to treatment, that's what matters.

And it was a really different mindset. And it, it actually shaped how I approached. Every infusion I didn't have the anxiety. I was okay. My tumor's gonna be obliterated. I have a tumor that is responsive to treatment. Let's see how responsive it's gonna be today. But I can imagine the levels of granularity of fine tuning that and the people who come after you're going to be able to do, are gonna be mind blowing.

Dawn Lemanne, MD: We will have patches on the arm that are like continuous glucose monitors that be continuous tumor monitors. Yes. And whether the medication's taken by mouth or, by patches on the skin or. By infusion, which I think will be an old fashioned way of delivering medication in another couple of years we can adjust the treatment in real time rather than three or four or six months down the road at your next scan.

Joelle Kaufman: Number one, if you could choose only one biomarker, but you're allowed to track it as much as you want to predict treatment resistance, what biomarker would you choose?

Dawn Lemanne, MD: To predict treatment resistance. So it wouldn't be the biomarker specifically, it would be the change in the biomarker. It doesn't matter what the biomarker is, it's how it's changing. That's what's important.

Joelle Kaufman: Awesome. Okay, so we don't care about the one. We care about the change delta. right. is the most dangerous assumption oncology makes about metastatic cancer?

Dawn Lemanne, MD: That treatment should be maximal and continuous, and that is a recipe for resistance development. That is how you create resistance in an ecosystem.

Joelle Kaufman: It's interesting because I think we've all become aware of that with antibiotics, right? We know that it, 

Dawn Lemanne, MD: herbicides and pesticides and in agriculture in any place that you look at large systems if you try to eradicate one particular element you will run into this, you'll run a biological system, you will run into this particular dynamic

Joelle Kaufman: It turns

Dawn Lemanne, MD: that there will be a escape.

Joelle Kaufman: right? There's something to this evolution concept. Systems

all right, so what, speaking of evolution, what is one thing you wish every oncologist would understand about evolutionary biology?

Dawn Lemanne, MD: Again, it's the same thing that cancers change. And we should try to steer that change rather than just accept it, follow it, and chase it until the patient dies. So we wanna get in front of it. We wanna play. One of my colleagues at Moffitt says We wanna play chess with cancer, not whack-a-mole.

Joelle Kaufman: That makes sense. All right. What's the biggest misconception patients have about metastatic cancer?

Dawn Lemanne, MD: Again, I think the idea that maximal treatment and pushing the tumor markers and the scans to NED or no apparent disease, no evidence of disease is beneficial and often that is counterintuitively that is the worst thing you can do in terms of long-term survival. You want to figure out how to manage the cancer, and if you push it down to near oblivion, what you've done is left the worst of the cancer cells to survive, repopulate, and finish the job.

Joelle Kaufman: Yeah. Survival of the fittest, right? You've killed off all the weaker ones, and what's gonna come back is the treatment resistant. Strained.

Dawn Lemanne, MD: And it's not survival of the strongest or it's fittest. And that's the fitness has to do these. The other the cancer cells that survive may not be that fit. In fact, they aren't, they're carrying these umbrellas around and when it's not raining, they're not as fit because they have to carry these the resistance machinery around, but they are able to survive the chemotherapy.

And whether they're stronger or weaker, then they're treatment sensitive rather than really doesn't matter. But certainly it doesn't mean that they're stronger, it just means that they have survived that particular drug. 

Joelle Kaufman: Okay. Thank you for the correction. All right. And if mathematical oncology becomes mainstream and these models are widely. Available. What do you think changes first?

Dawn Lemanne, MD: I think the idea that what'll happen is that these cancers that were universally fatal, people will live with them for a long time. And the semi- truth that your cancer is not curable, but it's treatable , which I think it right now is a bit misleading because I think it makes people think it's like high blood pressure or diabetes.

So the idea that it's treatable but not curable, I think is not true right now, but I think it will become true.

So as long as we are able to skillfully use the same drugs. What's beautiful about this is that we don't have to even find necessarily, there's nothing wrong with finding new drugs, but new drugs if they're used in the same old way, aren't going to answer. The question of the problem of drug resistance, even the new drugs we have, they all have the same problem with tradi resistance development.

So the first thing that will happen when these paradigms are used is that metastatic cancer will become a truly, if not cured, a truly treatable condition that patients can live with for decades.

Joelle Kaufman: That'd be amazing and a lot less scary for everyone. I love the role you're playing in kicking cancer's ass. The curiosity, the science, the innovation, the willingness to think outside the box. It's really inspiring. I wanted to ask a question about reaching populations that maybe aren't at the cutting edge or how do we make sure people aren't left behind as we're doing this level of discovery and precision medicine, and what are your thoughts about that?

Dawn Lemanne, MD: That's not been my focus at this point. My focus is on figuring out what works and how to get it to work in the patient in front of me. But I think that's something that patients have been becoming activists. And I think this began, back with HIV remember patient activists activism really taking off then and with breast cancer.

It may have started even before then. And so I think the patients are the ones that need to be and want to be and should be in control of doctors and what we study and how we study it. And I think that's where the that's how this will become available to everyone. Patients will say, we need this.

Joelle Kaufman: So if a patient walked into your office and was advocating like, that's the patient you want that partner. That person who's coming in with questions and wants to understand and challenge is that 'cause people don't wanna be disrespectful to a doctor, right? They're, you're doctors.

We're not.

Dawn Lemanne, MD: I think that that's long gone and I think that people are better educated now and they do have access to a lot of information. There does need to be some curation. oncologists are going to be better at that than a person off the street who hasn't thought about cancer ever and now suddenly has to think about it because they've got this diagnosis there.

There's, 10, 20, 30 years of thinking before that you're gonna get a higher quality of thinking about the situation. So please go and see an oncologist if you have cancer, a real oncologist. But yes, do your own research and homework. Be willing to do the work so no doctor is going to go to the gym with you or, measure your heart rate variability or, some of them might prescribe you a CGM, but in a lot of states now you can go get your own.

And so you definitely want to be active. If you're gonna be an activist, be active first in your own healthcare, keep your own records. Get the records from your doctors. Every time you see an oncologist, you know you get a little summary in the electronic health record. These are your pills, and your next visit is blah blah. That's not the real medical record, okay? The real medical record you have to go ask for and the doctor writes up a note. This is what I saw. This was a physical exam. This was how our discussion went and the patient seemed to.

Understand it or not understand it and decided to take my advice or decided not to, or that's the real record that you want, and please get those, keep them and show them to all of your doctors so that they all have a picture of what's going on with you.

Joelle Kaufman: That's great advice. I think for any appointment with your doctor by having the data and asking pointed questions it served me very well. It seems to have served all the different survivors I've talked to. And you are, as the patient, you're the quarterback, you're, it's your life

Dawn Lemanne, MD: I think patients need to understand that the doctor is not really in charge. I mean they are in a certain sense, but I. Not as much as you are and not as much as you should be unless that's, some patients do have the, Hey, I'm, this is overwhelming. Just tell me what to do and I'll do it.

That's a particular stance. I think that, that's less common now. And it depends on how sick you are too. Whether you have the energy to, to. To look into things. If you don't, then get a relative or friend to, to help you with that, to advocate for you. But yes, I think if at all possible, you wanna be the one in control.

And usually cancer's not a, ambulance calling emergency. You have some time to gather information and figure out what seems to be the best course for you.

Joelle Kaufman: And I think people forget that there's time. There's even time during treatment. There's time. And there's opportunities to learn. Dr. Lemanne, you've been very generous with your time. If our listeners want to, dig deeper into your approach into being their own best advocate, whether they're patients, caregivers, or even other healthcare providers, where can they learn more about the work you're doing and learn more about? The N equals one mathematical oncology. Understanding the right markers and looking for the right change. I would love your list of suggestions.

Dawn Lemanne, MD: Sure. So anybody is welcome to look at my website and take a look around. There's a course coming up that I'm giving on using personal health monitors like wearables, like CGMs, and heart rate variability.

Trackers fitness trackers, those kinds of things. If you're interested in that I think there's gonna be a URL up on your website as well for that. And so people are welcome to get in touch with me. I'm, I even answer the phone. 

Joelle Kaufman: Fantastic. Thank you so much.

Another episode of Kicking Cancer's Ass with all kinds of innovation and thoughts from the wonderful Dr. Dawn Lemanne. Thank you for being here.