Breast Cancer: It’s A Marathon, Not A Sprint

Nalini Chilkov, LAc, OMD

Thank you so much. 

Jennifer Simmons, MD

Today, we are going to talk about getting your life back, how to recover from breast cancer, and breast cancer treatments. But I have to tell you that I quote you nearly every day, because many years ago I heard you give a talk to a bunch of health professionals, and what you said resonated so deeply with me that it changed the way I approach everything. You said everyone who gets cancer gets a treatment plan, but what everyone with cancer needs is a health plan. 

That embodies what you do because you take it; you give everyone that extra something that makes all the difference in the world for them because that is the forgotten part of the traditional medical system: driving health, and it is never a part of anyone’s picture. 

Unfortunately, many of the things that happen while you pursue that conventional medical treatment plan not only promote health but also detract from it. I want to first talk about how you became an integrative oncologist. Because that is still pretty much a rarity.

Nalini Chilkov, LAc, OMD

Everyone has a personal story. Mine is that both of my parents were diagnosed with cancer in their fifties, and so I became interested in the thing that was most glaring to me: all the things the oncologists were not doing for them. One of the questions I ask myself now is, What can I do that the oncologist is not doing? I also realized that the oncologist’s goal for the patient is very different from my goal for the patient. The oncologist is fascinated by the tumor and the cancer, but not by much else—not by the person whose body is hosting the cancer, not by how they got there. They are certainly not interested in health as the outcome, that is my goal, and that is the patient’s goal for themselves as well. 

I think it is important for the patient and the family to understand that where the oncologist is going is not necessarily where you want to be going, and therefore you need a team. That is what I saw with my parents: that the oncologist was going to do this limited, narrow thing for them, which is necessary and important. But it is not going to get us where we want to go, which is to have our health back and our life back.

Jennifer Simmons, MD

You mentioned something in there and said that it was necessary. I want to break that down a little bit in your estimation. Because you have treated thousands and thousands of people for cancer, is it always necessary?

Nalini Chilkov, LAc, OMD

I do not think we can make generalizations about anything or the kind of medicine that you and I practice. We know that individualized decision-making and individualized medicine have the best outcomes. However, let me frame it this way. When you get diagnosed with cancer, your first goal is to reduce your tumor burden. That is your first goal. You have to ask, How am I going to do that? Sometimes surgery or chemotherapy is going to be a better tool than anything else. If you have a significant tumor burden, you must use those tools. If you have very little tumor burden, for example, breast cancer patients who are diagnosed with DCIS, it is an extremely low burden of tumors, and that may not require conventional care. However, it is not just about the diagnosis and how much tumor there is. It is also about whose body is hosting it. Is this a person who is 90 years old, who has poor immunity, has diabetes, is overweight, also has depression, and has a poor diet? 

Well, that is a different person than a 35-year-old who is an athlete, eats natural foods, is committed to doing everything, and is capable of doing everything that I ask her to do. I look at who is sitting across from me, but for the most part, patients are in our offices when they have stage two, three, or four cancer, which means their cancer is not local. It is not one spot; it has already traveled somewhere. All cancer is a systemic, whole-body disease. Even if you have stage one cancer, a tumor that is the size of the head of a pin, three millimeters, has a billion cells in it. The chance that one of those swam away to another location is there. You still have to think of cancer as a whole-body syndrome. The long-term solution to cancer is to transform the whole biosystem, not just the location where the cancer is. You still have to think of it as a larger project.

But I want to say, and I think this is important, that a cancer diagnosis is not urgent care; it is not an emergency. Oncologists make patients feel like it is. Cancer is a marathon, not a sprint. It is a long-term journey. It did not start yesterday, and it is not going to be over in two months. It is important to understand that cancer is a chronic illness. It is a chronic syndrome. The whole biosystem that hosted it—the cancer terrain, the tumor microenvironment—is a happy place for cancer to develop, grow, and progress. If we are going to have a real solution, we have to solve all of that. We have to understand the nature of the tumor, but we also have to understand the body that is hosting it. If we do not address both, we do not get a long-term solution. 

There is a third layer, which is that we have to understand the macroenvironment that is permissive of the cancer. Are you living in a toxic environment exposed to chemicals? Is your house full of carcinogenic toxins? Do you put carcinogenic body care products on your skin? Are you in a toxic relationships? All of those things have layers. You have to understand the tumor. You understand the host biosystem, and you understand the larger environment, which is giving rise to cancer. If you look through all those lenses, you will get a long-term solution. But that is not how oncology is practiced.

Jennifer Simmons, MD

Yes, unfortunately, I could not agree more with you that people have time to learn about what breast cancer means and what that diagnosis means. I think that people are so quick to identify with that pathologic tag that they are given. I have invasive ductal carcinoma, and it is grade 3, and we need help. Unfortunately, the medical system does feed into that. Let us get you in for surgery next week. Let us get you scheduled for a port. Let us get you, and you get put on this hamster wheel, and you are afraid. You are afraid. People do not tell you otherwise. If you are asking questions, you are kind of made to feel that you are a difficult patient. If you say, Well, what happens if I do not do anything away?

Nalini Chilkov, LAc, OMD

Yes.

Jennifer Simmons, MD

But I do want to say that I think that there are some instances where they are rare, but there are some instances where there is some urgency. To me, if someone has invasive, I am sorry, inflammatory breast cancer, You have underlying breast cancer, but you also have inflammatory changes in your skin, such as redness or even tumor erosion through the skin. That is a disease state that is fairly rapidly progressing. I think that person needs to be cared for. Another instance I can think of is if you have a disease that has spread to the brain, and the brain is a fixed space, so if you have had a seizure and have brain symptoms, that is also an emergency. Or if you have a bone disease that has caused a fracture or are in intractable pain, these are all situations that require an emergency. But I want to be clear: that is the absolute minority.

Nalini Chilkov, LAc, OMD

Those are not common things because, long before you are at that edge, you have had symptoms for a while. When we talk about who is sitting in front of us as patients, if somebody comes in and their breast skin is eroded—that has been going on for a long time before they walked in my office—or if they have a brain metastasis, they have been dizzy or losing their balance for a while. That tells me they are the kind of person who is maybe not connected to their body or that waits till it is bad to do something, and it tells me something about them so I can help them learn to intervene earlier, to speak up earlier, and to seek care. If they are coming in at the edge of an extreme diagnosis, how should they interact with their team and report to them everything that is going on? They get good care, and things are tended to now; not two weeks from now, they will have a problem.

Jennifer Simmons, MD

Yes, absolutely.

Nalini Chilkov, LAc, OMD

We are all socialized differently as patients. Yes, there are medically urgent situations, and hopefully, the daycare provider will explain them to the patient in a calm way. But it does not mean you have to go in tomorrow. Go on holiday, get your kids covered and your business covered. You are letting your psyche catch up to what just happened to you and making a plan. It is not an emergency if you are bleeding if you cannot breathe, or if you cannot speak. There are extreme situations that would take you to an emergency room. Have you been admitted to the hospital immediately? But that is not the case; most cancers have been growing for a long time before they are diagnosed. Yes, 10 years. This did not happen overnight, which means that you can take a little time and not give over your body, your time, your schedule, your decision-making, and your intelligence to the oncologist. You need a team. 

When you have a cancer diagnosis, you need the absolute best medical team and top doctors you can find. You need a health team, too. You, as the patient, are the head of that team, and we all work for you. This disempowerment and disenfranchisement that goes on in oncology culture is very damaging to the patient because losing a sense of control is one of the biggest psychological stressors in life. It is very important to take that back. If you are in a relationship with an oncologist who treats you like a child or is dismissive of your feelings, your intelligence, your values, and what you want for yourself, then find another oncologist because this is going to be a long-term relationship. If we have a healthy model, we also have to have healthy relationships.

Jennifer Simmons, MD

Yes. I think that is an important point that you bring up—that you are in charge. You get to decide what you want for your treatment and what you do not want for your treatment. It is so important to work with a provider who respects your opinion. If you do not have that, you have plenty of time to go find someone who does. What makes a good doctor subjective? Because, as they may work at the top hospital, they may have access to every research protocol there is. But if they are not human being that is open to discussion, answering questions, and respecting your opinion, they may be a great doctor on paper, but they are not a great doctor for you.

Nalini Chilkov, LAc, OMD

That is right. Even in my practice, someone might come in and say, I am not doing anything conventional; I only want natural treatments. Then it is my responsibility to respect them, fully educate them, and say, Well, take a look at it from this point of view, and let me expand your understanding. My part of my job is to educate you so you can make informed decisions. I might say to myself, Breast cancer is a treatable cancer. We know a lot about breast cancer. We understand that it is not cancer. We do not know what to do with it. Let us also just say upfront so everyone understands there are breast cancers. 

There are lots of different types of breast cancer. But we understand breast cancer well. We have lots of research that has been going on for decades. We know what to do for breast cancer. One of my colleagues, Dr. Kristi Funk, is one of the top breast surgeons here in Los Angeles. She says, Well if you get diagnosed with breast cancer, you should just expect to live. That is something important to understand about breast cancer. It is a treatable cancer. For the most part, it is not a death sentence. That is, I think, a big exhale to have at the beginning to understand.

Jennifer Simmons, MD

I think that that should be something that is said to patients on the first day, but it is not.

Nalini Chilkov, LAc, OMD

No, it is not. Well, doctors do not ever talk about mortality or death with patients. One of the first questions a patient has, subconsciously or consciously, is, Am I going to die? That strategy, I always say, since breast cancer is achievable cancer, I say, this is treatable cancer that you are going to die from. It was expected of you to live a long life. If we do everything, then that is important to hear at the beginning.

Jennifer Simmons, MD

Yes, I think that it is easy for people to understand what their treatment care team is. They know that they need a breast surgeon; they know that they need a medical oncologist; and they know that they need a radiation oncologist. If you are having a mastectomy, they know that you need a plastic surgeon. I do not know that people know who’s on their healthcare team. Could you talk about the healthcare team?

Nalini Chilkov, LAc, OMD

I think that also varies for patients. But I also want to say that I do not think people know that they need all those things either.

Jennifer Simmons, MD

That is, a lot of those things are not readily accessible.

Nalini Chilkov, LAc, OMD

Yes, they are. A lot of patients do not know that there are these different players that are going to be on their medical team. I think that it is also important to make that explicit. I have to say, I have a new patient, and I was just reviewing her records yesterday. She is a patient at Cedars Sinai Hospital in Beverly Hills. I was so impressed that her oncologist sent her to have a psychosocial evaluation and have somebody talk to her about the stress and how she is feeling about the stress of the diagnosis. Her oncologist also sent her to someone to explain to her what to expect when she goes into the infusion center for her chemo, what kind of side effects to expect, how those are approached, and that they are all manageable. This is all happening before she starts her treatment.

Jennifer Simmons, MD

That is amazing. 

Nalini Chilkov, LAc, OMD

That is a forward-thinking cancer center with the right approach. Trying to appreciate the patient’s predicament and fears.

Jennifer Simmons, MD

Absolutely.

Nalini Chilkov, LAc, OMD

Need for information.

Jennifer Simmons, MD

I hope that that is something that they practice across the board and did not do for this patient because they perceived her to be difficult. That is my cynical brain, but I hope that that is something that they practice across the board at this place.

Nalini Chilkov, LAc, OMD

In this cancer center, every cancer patient gets a nurse, an oncology nurse, who is their advocate, and who helps them think through what their questions are for the doctor, who knows what is going on with them and is the liaison to the oncologist, who’s not always available directly to the patient. This is their model of care. They also have the option to do yoga for cancer, meditation for cancer, or acupuncture for cancer. This is a model cancer center in California.

Jennifer Simmons, MD

Amazing.

Nalini Chilkov, LAc, OMD

Now, the culture of medicine is an early adopter of new ideas. But that does not mean, if you are a patient somewhere else, that you cannot bring these ideas to your journey.

Jennifer Simmons, MD

Yes, absolutely. I completely see what you are saying about the kind of conventional all-health care team breaking out. But I do think that that system is unique and not happening across the country. I know for a fact that it is not happening in Pennsylvania, where I am. How does someone go about building a health team? What are the components?

Nalini Chilkov, LAc, OMD

I think, again, that is somewhat individualized, but just the other pieces of ourselves, so that the first two questions patients ask me all the time are: What should I eat and what supplements can I take? You need someone on your team who can answer those questions for you. That is one person so that might be someone myself. That might be a naturopathic physician; it might be a nutritionist who specializes in cancer care. somebody—you might have someone who is an acupuncturist. I am a big proponent of acupuncture for cancer patients. If you struggle with emotions and coping, you might want to be under the care of a psychotherapist, a social worker, or a counselor who can help you grow your muscles, your needs, and your coping skills to be able to succeed and thrive. 

As you go through this, you might want to have a yoga teacher, an exercise coach, or whatever you think you need. But you need people who understand wellness and health and support healthy function, but who are also experienced working with cancer patients because the needs of cancer patients are unique. You do not want just anyone. We are lucky around here to have your yoga instructor know what is going on with cancer patients’ bodies and what they can do when they report in their bodies and when they cannot. We have nutritionists who understand the unique needs of cancer patients. 

For example, I have a nutritionist who works in my practice and is also a cancer survivor herself. When I introduce her to my patients, I say, Well, not only is she knowledgeable about your unique needs and challenges as you go through your cancer journey, but she is quite an inspirational person. You just meet her for that reason as well. That means maybe you want to be in a support group of some kind, and those can be positive or sometimes negative for patients because if there are a lot of people there who are doing poorly, that can scare a patient who is just at the beginning of their journey. You want to find a group that is a good fit and a good match for you as well. Quite often, oncology nurses are great allies, and they can answer so many of your questions and put you in touch with other resources because they are the ones who are there next to you, knowing what you are going through. 

Quite often, they are fabulous resources and allies for you. Let us say you are on a 21-day chemotherapy schedule and you are coming up for your day, for your next infusion, and you just do not feel well enough this week to do it. You can talk to the oncology nurse, and you can postpone it a week, but patients feel they will die if they do not stay on their schedule. You have somebody to talk to. Let us say you are in surgery, you are in the hospital recovering, and your fear of death is coming up. You do not know if you are going to survive. You are worried about your kids and all of that. 

You can ask for a hospital chaplain to come in and speak with you. They are multi-denominational, and they are highly compassionate people skilled at talking with you about what you are going through at this moment. You might want to avail yourself of your church group or your spiritual teacher. Don Abrams is a well-known integrative oncologist. He asks his patients, What gives you strength? What gives you hope? What are your dreams for yourself, and what is your spiritual life? You asked that on the first visit. He knows something about who they are and how they help them. I think that is important to ask ourselves,?

Jennifer Simmons, MD

Yes, it is important to ask ourselves, and the number one predictor of who will survive and how long you will survive is how long you think you will live and what you have to live for. People who want to live and live with purpose live far longer than those who do not.

Nalini Chilkov, LAc, OMD

Yes. People who love life live longer. We also know that people who have good support systems live longer. I practice in a multicultural city like yours. I know that when I have a Latin patient, I have to put eight chairs in my room.

Jennifer Simmons, MD

Yes, of course. The whole family’s coming. Yes.

Nalini Chilkov, LAc, OMD

Then there are those people who have no one and are going through it by themselves. Then my team has to become their extended family and tell them that we are going to be there for them. 

Jennifer Simmons, MD

Yes, and that is better.

Nalini Chilkov, LAc, OMD

For them to build a support system. Sometimes that is the developmental challenge for some patients: learning to ask for help and receive love, care, and help. That is one of the gifts of the experience: getting to work through it.

Jennifer Simmons, MD

Absolutely. Can we start to talk about some of the nuances? What is the difference between conventional oncology and integrative oncology?

Nalini Chilkov, LAc, OMD

Yes. It is important to understand that. Conventional oncology, as we mentioned before, is focused on the disease and how to reduce your tumor burden and take control of the disease. In some cancers, they do well, but not so much. In breast cancer, there are a lot of resources. 

The toolbox of conventional cancer care includes surgery, chemotherapy, radiotherapy, immunotherapy, targeted therapies, and hormone therapies. All of those are available to breast cancer patients. 

Today, if you are diagnosed with breast cancer in a conventional setting, the first thing you should ask for is individualized decision-making. You should make sure that they analyze your tumor so that decisions are made based on the type of tumor. There is a more cutting-edge cancer center looking at your tumor. They are looking at your genetics before they decide what they are going to do. You should ask for that. If you do not if you are just being given some cookbook treatment plan, you should ask for individualized decision-making and take all the steps that would allow that to happen.

For example, there are women that we now know if we apply a series of tests that do not need to have chemotherapy, they will do just fine if they do not have chemotherapy and will do fine just with hormonal therapy. We want to know if you are one of those women. We do not want cookbook medicine. We want individualized decision-making. When you go in as a patient, you ask for that. In some HMOs where not spending money is the main goal, you say, I feel it would be medically negligent just to do a cookbook medicine on me. I want individualized care. I think it would be medically irresponsible for you not to ask and answer these questions before we decide what the best treatment for me is.

Jennifer Simmons, MD

What kind of questions are those? Are you talking about asking for something different or pivotal?

Nalini Chilkov, LAc, OMD

Just that. The testing changes all the time. I want to tell the patient what to ask for, one of the categories of things to ask. Has my tumor been analyzed? Have my genetics been analyzed?

Jennifer Simmons, MD

What you want out there is to make treatment recommendations based on tumor analysis and genetics. In this generation of things, we are talking about things like the archetype or mama plant to determine if you would benefit from the chemotherapy we are talking about.

Nalini Chilkov, LAc, OMD

I just want to interrupt for three minutes. I think that these things are already outdated where I practice. I want to put those words in patients’ mouths because there are better tools now than those. I want the patient to ask for the most cutting-edge analysis of their tumor and their genetics because they are changing all the time. I live in a city where those are not the main tools being used. They were being used when they were the best tools. I think it is important that patients do not have all the information that might not be relevant to the cancer center where they are going to receive their gear. 

They want to ask for an analysis of the tumor—a thorough analysis of the tumor—which could be a variety of types of tests with different names and an analysis of their genetics. For example, everyone should be tested for BRCA, and that used to never be routine, but it was because the test was too expensive. Now it is cost-effective. Every single patient should have that test because more aggressive cancers require a more aggressive approach. If you have had a biopsy, you have tissue that has been analyzed, and you will know whether or not you have a fast-growing aggressive cancer or whether you have a lazy cancer. You will know whether you have hormone-driven cancer or not. You will know whether you have other traits. Those traits define what we are going to do and what we are not going to do.

Jennifer Simmons, MD

Do you think that is not routinely done? Because of this.

Nalini Chilkov, LAc, OMD

Basic things are done. The most basic things are done everywhere. But what is not done is a thorough genetic and receptor analysis of the tumor and a thorough genetic analysis of the patient. Those are not routine because they are expensive. If you are in a place where they do not want to spend money, they do not do it.

Jennifer Simmons, MD

Well, I think that is helpful to a point. I only worry that there is still a lot of paternalistic medicine being practiced. Do not worry about it, your pretty little head. We know what to do. We are all having an opinion.

Nalini Chilkov, LAc, OMD

Go get a second opinion, and a true second opinion is outside the sandbox where the oncologist you are talking to is located. If you live in a small town, go to the closest big city. If you live in a big city, go to another cancer center where there is a different milieu of doctors. But if you are not comfortable or do not feel you are being respected, get a second opinion. Get a third opinion on your insurance, and we will pay for those opinions.

Jennifer Simmons, MD

I think that an important point is that you should. I think everyone should be getting second and third opinions.

Nalini Chilkov, LAc, OMD

Now, what cancer patients need to understand is that insurance pays primarily for the standard of care, which is cookbook medicine. If you have a strict diagnosis, you get a certain treatment. However, that is changing, which is why the patient needs to be educated, because now treatment can be based on saying, I have these receptors in my tumor, so I have this genetic trait or I have these genes driving my tumor growth. Then, if you are outside the cookbook, you are outside the cookbook. More thoughtful decision-making can be made. But doctors and patients do find themselves in a predicament where what gets paid for initially is the standard of care. If the standard of care fails, then you get individualized decision-making. But I want to see us not have to go through that.

Jennifer Simmons, MD

Yes. My goodness.

Nalini Chilkov, LAc, OMD

We could have made a better decision at the beginning.

Jennifer Simmons, MD

Yes, and people should be entitled to not be subjected to experiments, We should know from the start what is most likely to work. We should not be guessing. We should not be part of medical experiments. We should not be part of it. Well, let us try this first. then, if that does not work, we will do more testing, We should be doing this testing upfront.

Nalini Chilkov, LAc, OMD

That is what the standard of care is. But cancer care decision-making is changing so much that you can ask for that. The other thing you asked me is: what is happening on the other side of the integrative oncology side. On the health side, I want to know what your vitamin D levels are, your blood sugars, your insulin levels, your inflammation levels, your copper, your zinc, and if you have diabetes, autoimmune disease, cardiovascular disease, or depression, I need to build a plan for you. I need to know if you are a single mom and your kid is two years old. I need your life so I can plan something together for you that is going to get you through this with success. 

We are looking at diet. What kind of diet optimizes the cancer terrain so that you will not host cancer so readily? The biggest piece, the biggest lever, that you can do is eat a low-carb diet because most cancer cells, particularly breast cancer cells, have more receptors for glucose. Something called Group 4 is for insulin. So if your blood sugar is higher and your insulin is higher, then you are going to get more growth signals from your breast cancer cells. If you are a breast cancer patient, you want to eat a low-carb diet so that you take away the glucose and the insulin. So that is one of the most powerful things you can do. I want to see people do that under the supervision of a nutritionist because what happens to most people is that they take the carbs out and lose weight because they are not getting enough calories. When you do that, you need to replace the calories with more healthy fats and oils. You also need to make sure that you are getting enough protein as people get older. 

The demographic of cancer patients is over 50. Typically. At that age, you are losing muscle mass as a matter of aging physiology. Cancer physiology accelerates the loss of muscle mass. Every cancer patient is at risk of losing muscle mass at an age where you kind of eat less protein anyway. It is very important to eat enough protein every single day. When you are going through training, you do not feel like eating sometimes. I always put a protein shake into the plan as an insurance policy. You can have 20 to 30 grams of protein in a shake. I have to write patients to get around with around 70 or 80 grams of protein if they are over 50 while they are going through treatment because then they are not going to lose muscle mass. What makes you feel weak is the loss of your muscle mass, and so it is hard to eat that much protein. 

Most women do not eat much food. I think that a protein drink is a great source of protein. It is a good insurance policy. You do not have to drink the whole thing at once. You can sip on it for a couple of hours and take your supplements with it. You can make a big shake in the morning, make another half-shake in the afternoon, and have more protein-bone broth. Real bone broth has 10 grams of protein per cup. That is an easy way to get another 10 grams of protein. Drink it as tea, flavor it with ginger, garlic, or Oregano, and make it taste good. Use it as a base for a soup. But I also help people drink bone broth while they are getting their infusions. Because you need electrolytes, you get all this glutamine with it, which heals the lining of your gut. Most chemotherapy is going to damage the lining of your mouth, your intestines, and your esophagus. If we immediately put in fluid electrolytes and glutamine while you are having your infusion, you are going to have some repair going on, and you will not feel as fatigued after your infusion because you are hydrated and you have electrolytes. 

There are just a few simple things that you can do to make a big difference. We just set three of them, make sure your protein is adequate, and you can use a shake and bone broth for that, and go on a low-carb diet. What does that mean? That means anything that tastes sweet on your tongue, you are going to take out of your diet; you are going to reduce all sweeteners; and you are going to take the fruit out of your diet, except for maybe one cup of berries a day. You are going to take starches and grains out of your diet, too. Your plate is going to have half-colored vegetables. You are going to eat the rainbow because you are going to get all those phytochemicals, which are the pigments that color fruits and vegetables. Those are talking to your genes, and your body is a chemistry lab. We are going to have all those phytochemicals from the colors in plants that are going to turn genes on and off. We want to turn on the cancer suppressor genes and turn off the cancer promoter genes, and that is why it matters what you eat.

Jennifer Simmons, MD

Awesome. I love that. While we are talking about what you eat, where do you fall on the fasting thing?

Nalini Chilkov, LAc, OMD

That depends on who the patient is. If I have, again, a 35-year-old athlete with plenty of muscle on her and she is not in aging physiology, she can fast. But if I have a frail older woman who already has lost muscle mass, she is not going too fast. She. So we have to decide that it is more important to preserve muscle mass. Now, you are asking that question because fasting does increase the efficacy of chemotherapy. Why does it do that? Because cancer cells have a different metabolism than healthy cells, cancer cells primarily use glucose as fuel, while healthy cells are much more metabolically flexible. If you drop your blood sugar by fasting, the cancer cell is highly stressed. 

When you get the chemotherapy infusion, you have a stressed cell getting that chemo. You get a better therapeutic effect, and the healthy cell can adapt to fasting physiology and is not so damaged by the chemotherapy. It leverages the vulnerabilities of the cancer cells too fast? However, you cannot fast at the expense of your health. You cannot go into an infusion dehydrated. You must be hydrated. You must have fluid in electrolytes. I prefer my quick patients to fast on bone broth. They are getting fluid, electrolytes, and protein, and then they are safe. We can say that is a general recommendation. Everybody’s safe when they are going into it. But if you have somebody with kidney disease, some diabetics, or somebody who has neurological issues, you need that to be a medical decision. Whether you should fast or not, you should be evaluated, and it should be decided if you can or cannot fast and if you are too fast. 

I had a young woman yesterday. It is a new patient, and she is a little bit overweight, and she is in her 30s. She is not worried about losing muscle mass; she asked me if she could go fast. I said, Yes, you could fast for 48 hours before and on the day up to the end of the infusion, but it is hot here so she has to be on top of her fluid and electrolyte. She cannot be dehydrated, either. I suggested that she make bone broth because, when you have protein, you are also going to hold on to your fluid a little better. Then we are safe. We are safe in the summer with that patient. I always suggest that patients take extra magnesium on their infusion day because most chemotherapy will deplete magnesium. That is part of the fatigue.

Jennifer Simmons, MD

Interesting.

Nalini Chilkov, LAc, OMD

Yes. If somebody cannot fast, then I have them bring a protein drink in a thermos to their infusion so that, with no fruit in it though, a low carb, no carb. You are just going to have protein powder and water, maybe cinnamon and vanilla, and maybe some MCT oil in it, which is a coconut oil derivative, and maybe a little fiber powder. You can have that. You can bring a big thermos of that. Well, you are there at the infusion center. You have been there for hours. Bring a movie, something to read, something to eat, and you do not have to sit in your chair. That is the other thing. Just sit there, get up, and walk around. You should not sit there. You are more at risk for a blood clot when you are receiving chemotherapy, and you are more at risk for a blood clot if you have cancer or a tumor burden. You do not want to be sedentary. You want to be hydrated while moving around.

Jennifer Simmons, MD

While you say that? Let us talk a little bit about exercise while cancer is running, because I think that part of that fatigue part that you talked about is that our bodies are very much if you do not use them, you lose them. People who become sedentary during cancer treatment have more fatigue and worse outcomes than people who are not. Can you talk about that a little bit?

Nalini Chilkov, LAc, OMD

The research on cancer and exercise is pretty compelling. A lot of it has been done in breast cancer patients, and we know that breast cancer patients regularly have better outcomes and better survival. We know that breast cancer patients who do intermittent fasting have better survival. We will talk about that in a minute. But exercise is very important for your psychology and your mood. It is important because you need your kidneys to be filtering in. You need your blood to be circulating through your liver. You need to be breathing. You need your heart to be beating. You need your muscle mass and muscle tone to be there, and I want you to go out and work in nature if you possibly can. If you cannot, I want you to dance in your living room. I want you to do something. 

People can feel wiped out. I say accumulate an hour of movement every day. I do not care if you do it in 10, 15-minute increments; I want you to accumulate an hour of movement. You are not to sit all day. I have a patient who has been diagnosed with pancreatic cancer. She felt pretty lousy, but she thought up a diagnosis. She was supposed to go to bed, stay in bed, and be convalescent. Then I went, no. First of all, you need movement to have a normal, healthy physiology. Secondly, people who stay in bed want to sit up and stand up on their own. She became so weak that she had to be in a wheelchair because she just went to bed and did not need to do that.

Jennifer Simmons, MD

Yes, it is such a sin. But I think that is a part of the perception, and I wish that that was talked about more.

Nalini Chilkov, LAc, OMD

A pace of behavior. This patient I saw yesterday, is starting chemo today as we speak. I said that the anxiety that patients have before their first chemotherapy infusion is way out of proportion to what the reality is going to be because if you think of it as some Frankenstein story or something, you see this. But what is important to understand is that chemotherapy is done extremely skillfully today, and it is done in a very thoughtful manner. We do not use the super-high doses that were done 20 or 30 years ago. You are also given anti-nausea medication and an anti-inflammatory medication while you are having your chemo. You do not have a lot of issues coming up, and you are watched closely by a nurse the whole time. It is not. It is more psychologically traumatic than physically traumatic. Once you have had your first chemo, you realize that. But I think that preparing a patient for chemotherapy so they are not so anxious is important as well. 

Also, for the patients who come into my office and say, I am not doing chemo, I say, Chemo is not the enemy. Cancer is the enemy. The question we have to ask is: Is chemotherapy a tool we should use for you or not? Is it part of the solution? Is it not part of the solution? If we think it is part of the solution to reduce your tumor burden, then manage the side effects for you. It is a finite thing in a person’s life. Maybe it is going to be a four- or six-month window of time, and it is over. It is going to be over, and you are going to recover from it. It is made to be this monster that it is not, and it is part of the solution force of patients. It is important to welcome it as a useful tool and then have this fear of it. It is a manageable therapy; it is a manageable point.

Jennifer Simmons, MD

I think it is a lot about mindset in that, if you believe that it is going to help you, it most definitely will. If you believe that all it is going to do is hurt you, then that is exactly what is going to happen.

Nalini Chilkov, LAc, OMD

Well, you will have side effects. You will have more side effects.

Jennifer Simmons, MD

But that is what is hurting you, Yes. So I think that our approach, the way we frame it, is very important, and as my mentor, Gordon Schwartz, used to say to people, it is some short-term misery for long-term gain. I think what you are saying is that a lot of that misery is now perceived. It is a preconceived notion because we have come a long way in mitigating the misery.

Nalini Chilkov, LAc, OMD

Well, we use much lower doses, much more skillfully. What patients need to understand, too, is that if they give feedback to the nurse and the doctor, then the dose can be adjusted. If you happen to metabolize that drug differently than the patient before you and you require a smaller dose to get the same therapeutic effect, that can be adjusted, but you have to communicate.

Jennifer Simmons, MD

Yes. That is what is so kind of revolution, about how we approach it today: the studies may have been on a particular dose, but that does not mean that it is your dose, and you should be working with someone who is going to adjust based on you and not on what the study said because everyone is different, everybody’s a bio-individual, and what is good for you. It is not necessarily what was done in the study. Working with someone who has that kind of relationship with you, who hears you, and you are openly communicating with them and saying, I do not know that this is for me. 

You did mention that you recommend people take magnesium on the day of treatment. Are there other recommendations that you have for them while they are actively going through chemotherapy and radiation?

Nalini Chilkov, LAc, OMD

Well, the main thing for chemo is to be hydrated and to be replete in your fluid, in your electrolytes, and magnesium. Those are the main reasons I recommend Magnesium Glycine 8, and I recommend most capsules of Magnesium Glycine 8 or 140 or 150 milligrams. I recommend taking it three times a day on the day of chemo, and maybe for that first week of chemo. It is a nice thing to keep your magnesium replete, and it is important to stay hydrated. You want to keep diluting your blood and letting your kidneys filter. That is important. Of course, you should get up and walk around. You facilitate that filtration as well. Having enough protein is important if you are fasting. I still think it is important if you are going to fast for two days before, and the day after that, make sure you step back on your protein or your protein shake. It is important because when tissues break down, we need to build them back up.

Jennifer Simmons, MD

What about, do you advocate for any resistance training, our weights, or anything else to try to preserve muscle mass during this period?

Nalini Chilkov, LAc, OMD

I ask the patient, am not an exercise physiologist. I ask the patient what they should do. I see what they are doing, and depending on who they are, there is somebody who’s never exercised. Just ask them to accumulate an hour of walking every day. However, it is important to have a complete exercise routine, whether you are healthy or going through cancer. That means flexibility, strength, and cardiovascular. 

I think, for example, yoga and Taichi accomplish all three of those things. Plus, you get peace of mind from thinking about things. It is the older patient I have talked to most often. There are things you could do until you are 90. You do yoga and Taichi until you are 90. You can walk and stretch till you are 90 with these little free weights. I encourage people, I think, first of all, to just tell me how much the benefit of their survival exercises makes them do it now and just start to make their lives change by doing that. A lot of the things that promote longevity in terms of diabetes risk, cardiovascular risk, brain health, and cancer, are all the same stuff. Exercise is important for healthy aging in general. Again, I will make referrals appropriately. I am not usually designed to name but of there.

Jennifer Simmons, MD

Definitely. But the message coming from you—I think the studies show that even one hour of walking a week increases survival in breast cancer patients.

Nalini Chilkov, LAc, OMD

Well, no. That is not enough. No, you have to do 30 minutes five days a week to help increase survival.

Jennifer Simmons, MD

Yes, I could not agree more, but some studies show that I would never benefit.

Nalini Chilkov, LAc, OMD

Studying people does it? Yes, I chose my references. This is because I want them to do more. This course also lets you say you have had surgery. All women who have hysterectomies should have pelvic floor exercises, but that is not routine. We have to make appropriate referrals from the health model so that the patient does well. Some breast cancer patients who are positive are going to be suggested to have their ovaries removed. Any pelvic surgery can cause a change in your pelvic floor and the muscles holding up all your organs. Why isn’t that just part of the prescription post-op? When you are in a health model and you have a clinician yourself or myself, we are going to make sure you do well. We are going to make sure you do well. Exercise is part of that. Exercising your pelvic floor can be part of it, too.

Jennifer Simmons, MD

Absolutely.

Nalini Chilkov, LAc, OMD

With breast cancer, if you have a mastectomy, one of the biggest reasons I always have people work with a physical therapist after their mastectomy is for several reasons. One is, that a lot of people start to do this, and you want to maintain your upright posture. You also want them to have incisions in your pectoral muscle in the upper chest. You want to make sure that gets strengthened. You want to have a full range of motion in your arms. A lot of breast surgeons will sew up women so tight they cannot do yoga; they are too tight. I always say, Talk to the doctor, who will tell you to do yoga. You want to have the flexibility to do your breast surgery, and then women who have lymph nodes removed need to have them with a physical therapist who is a specialist in lymphedema, which is the fluid retention that can happen to your tissue when you do not have lymph nodes to drain that fluid into the circulation. 

That is just my standard of care. After you have a mastectomy, after you have lymph nodes removed, you get these referrals. You learn. You do not develop problems. You do not need to be developing. You learn what you need to do to move that fluid and not have your arms swell up. This is not the standard of care. If you have a health team and someone looking out for your health, you going to get this as part of your plan.

Jennifer Simmons, MD

Yes. I could not agree more. It is so important to move after any surgery, especially if you have had lymphatic surgery because you want to. When you exercise, there are circulating factors that help to reestablish lymphatic circulation and vascular circulation, and you want all of that. When I started breast surgery, we were told that people should rest on that side and not use the arm. That was the worst advice that we could give. That was the standard of care advice for 20 years.

Nalini Chilkov, LAc, OMD

Well, and I even tell people, after the surgery, of course, you will want to move your incisions around your heel. But I just say, Just go fold your arm under your breast and go for a walk, and just a gentle lot. Do not just sit around. Yes, psychologically, it feels better to have a more normal day.

Jennifer Simmons, MD

Yes. We know that exercise and movement is the number one thing anyone can do to stave off depression.

Nalini Chilkov, LAc, OMD

To stave off the risks of surgery.

Jennifer Simmons, MD

Yes. Is there anything I know we have talked about so much? Is there any point that you want to leave with people? 

Nalini Chilkov, LAc, OMD

Yes. I think some of the most important things to understand are that you want to have a health model, not just a disease model, and when to plan for your health as part of your cancer experience. That is the long-term plan to plan for your health. Do you want to take control of that? You want to understand that you are the head of your team. You want to have care providers that treat you with respect. If you do not go interview some other doctors and find a team, because these are going to be long-term relationships, you are going to be followed for a long time. 

Then just get the basics in place. Make sure you drink enough fluid every day, exercise every day, and get enough sleep. Make sure you are on a low-carb, high-fiber, or eat the rainbow-adequate protein diet. Take a look at your environment and make sure that you are not exposed to carcinogenic chemicals. In the case of breast cancer patients, hormone-disrupting chemicals—that is why a lot of our body care products have parabens in them, for example. You want to learn the brands that do not disrupt your physiology. You want to care for your psychological and spiritual health, and you want to realize that you can reframe cancer as a transformational experience and a gateway in your life that gives you the opportunity for self-reflection and reevaluating your values and priorities. What has meaning for you? A lot of patients go through the cancer experience in this more self-reflective kind of way, transform them, and come out saying, paradoxically, that cancer is the best thing that ever happened to me because I am now congruent with myself, my values, and what is true for me. I have also now had a life that causes health rather than makes me vulnerable to disease. 

I think you have to realize that you can take steps to make that your reality. It is a learning curve, so you cannot do it by yourself. You need help. You need wise women around you. The wise professionals around you, and your loving friends and community are all part of that outcome. But that too—to have that vision that that is what your outcome is going to be—I think that is important. If you are a mother and you have children, having your children see how you meet a life-threatening challenge is a lesson they will never forget as a nonverbal lesson. But to see how you meet that and what you do with it, and that you stand up, you take, you keep breathing, you keep your head up, and you do things that are constructive and towards life. I think asking the question, What causes me to thrive? is a better question than asking what is wrong. I think doing that for yourself changes your psyche, but the impact it makes on your children is huge and for anybody around you, it is easy to do that. I think we need to reframe what this is so that we get these kinds of outcomes and that it becomes a transformational experience.

Jennifer Simmons, MD

You and I have this amazing privilege to watch the people who choose to see it as a transformational experience transform, and some of them achieve better health after their diagnosis than they ever had before. It is amazing to watch. I am sure that you feel the same way in that we have the God-given privilege to see miracles every single day. The human body and its abilities and capabilities are astounding when you do what nourishes your body. Living a life that causes health brings great, amazing things. 

Dr. Chilkov, thank you so much for being here today and for sharing your wisdom, for doing what you do, and for providing hope and this amazing perspective to people who are probably at the worst time in their lives and you show them a gateway to the best time.

Nalini Chilkov, LAc, OMD

Thank you. It is an honor and a privilege to bear witness to people’s courage and transformation.

Jennifer Simmons, MD

Sure is. It is Dr. Jenn. Bye for now.