The One Test That You Want To Fail

Introduction and Speaker Background 0:00

Hi, it's Dr. Jenn. So I couldn't be more thrilled to be talking to our next speaker. This is a man who needs no introduction and certainly needs no introduction if you stalk him like I do on social media. But given the scope of expertize as he's probably the most important person to talk to on the topic that we're going to talk about today, which is the 800-pound gorilla in the room. So I would like to welcome Dr. Joel Kahn, America's cardiologist, to the summit. Thank you very much. I'm a really important topic, so I'm excited to be here with you, but I'm excited to share with your dynamic and great audience.

Yeah. So why don't we start by just give everyone a little background where you started, where you are now, so that they can get a sense of who is talking to them. As I'm just about to turn 64 and I started and I'm ending about a mile apart because I grew up a mile down the road. Before my family. I'm in Suburb in Detroit, grew up here, attended the University of Michigan in Ann Arbor, figured out I was a pretty good student because I ended up graduating number one from med school class and oh, yes, I'm not going in the family furniture business.

I guess. Not. I wanted to be a cardiologist even while before that. Just a random few things, like a heart murmur I had as a child. And I stayed in Ann Arbor for a while, wandered to Dallas, Texas, University of Texas, Southwestern, and then I became a cath lab guru. I spent a year in Kansas City, and in 1990 I came out as just ready to take on the world of you had a blockage. I was ready to balloon it and later stent it. And I did that for getting close to 30 years. But the only other quirk in my life is I adopted a Whole Foods plant based diet when I was 18 years old.

Very honestly, I hated the dorm food. They had a great salad bar. It wasn't a real ethical or global environmental decision. It was just surviving. I had a girlfriend with me who did the same move. She's been married to me for 42 years and tolerates me. And we discovered a few years later that we were in Ann Arbor and I guess we were vegan. And around then I heard of various doctors like Dean Ornish and the Pritikin Center, and I realized there was something to this odd nutrition pattern, and I was following in my colleagues work.

So that just to end my intro, I've always had dual track standard hospital, standard cardiology, aggressive what's called interventional cath lab cardiology and a real curiosity into prevention, nutrition, early diagnosis believing you could reverse Atherosclerosis you could identify it early. And about eight years ago, I stopped doing the hospital cath lab work just like you did with your surgical career and said, you know, there's a lot of surgeons out there, there's a lot of cardiologists out there.

But there sure is not an overwhelming number of preventive and integrated ones. So that's all I do now for people all across the United States. Some degree the world is trying to teach them, test them and get them on a better path because we are dealing with that big elephant, like you said, the number one killer of men and women. And it's a serious disease. I mean. Yes, it is now. Thousand people a day, a little more than a thousand a day just drop dead suddenly of heart disease. You know, when you're dying of cancer, it's tragic.

But your family has a little time to be around you. Hopefully when you drop dead of heart disease, nobody said goodbye. You know, it rocks people's lives. They're never really the same and back again. And yeah, we have the ability to drop that number. And, you know, half of them are women and some of them are women with breast cancer. So there's lots to talk about here. Yeah, for sure. And the reason that it's the 800-pound gorilla in the room is because people really are not talking about it. I mean, that number, a thousand people a day, that's astounding.

And in every decade of a woman's life from 30 on and correct me if I'm wrong, heart disease is exponentially more of a threat to life. Right? Right. I estimate that the number of women, decade by decade after about age 45 that die of heart disease is ten times more than die of breast cancer. Now, we don't want anybody to die of breast cancer, and we obviously don't want anybody to die of heart disease. But when you think about all the attention made to breast cancer detection and obviously early treatment and long term survival, where's the ten time focus and ten kind?

The occasional effort on, wow, checking your breast and checking your goal and you got this organ between your colon and your breast called your heart, maybe out to check it, too. And it's really very simple to do that. Nobody should walk around unaware that they have silent heart disease. And it's just it's one test away from knowing the reality. So let me let me ask you this, because people are everyone is aware of the breast cancer statistics.

Heart Disease as the Leading Women's Health Threat 5:43

Right? Everyone knows one in eight over someone's lifetime. Everyone knows that there's a 12% chance of breast cancer. But the numbers of heart disease and deaths from heart disease, they dwarf breast cancer. So where are the red ribbons? I mean, we are swimming in a sea of pink ribbons. Where are the red ribbons? Right. You know, some of those numbers in the last cut I saw was 2021. 700,000 people in the United States died of heart disease. About a thousand a day where these sudden deaths with no warning and no goodbye and no kiss. I love you.

Just dead in the bathroom, in the bedroom, on the sofa at work. Tragic stuff, but all those people essentially could have been detected ahead of time, and most of them could have had efforts to prevent that and certainly at least delay that. And half of that is women. About a third of women will die of heart disease, and that's ahead of every cancer. Combined is number two. And briefly, in 2020, COVID was number three or 2021, but that's dropped off. So we have a whole lot of other tragic conditions.

But let's not go there. And, you know, there's women concerned about their breasts. Health should be concerned about their heart health. There's a lot of overlapping risk factors. You know, as age increases, breast cancer risk goes up. As age increases, heart disease risk goes up as diet is off the Western. The process, the ultra fast food diet that so many people eat either because of stress or finances or their urban situation and such. Well, you know, it's the same diet that feeds heart disease, feeds breast cancer.

There's some data about alcohol intake and breast cancer and lately there's been a trend away from endorsing alcohol intake and heart disease. Obesity would be the last one I mentioned. You know, it's not body shaming, it's just science that increased risk of cancer and obesity, increased risk of heart disease. So if you just think about it for a minute, this is the single most important statement I'm going to make, that when people are about 45 to 50, they're going to start hearing, you know, you really ought to get their mammograms scheduled.

You ought to get that call and ask to be scheduled, maybe you'll do the poop test called Cologuard. A guy is going to get a digital rectal or a PSA blood test for prostate cancer. A woman's going to see her gynecologist and get a gynecologic exam for cervical cancer screening over there. Like I just listed every formal screening for serious diseases that takes place during a physical exam with your internist, family doctor, nurse practitioner, gynecologist. Where is the heart screening test? And there's this giant deficit in western medicine and a giant deficit in the United States specifically that there's no discussion.

You know, Sally or Mary or Jane or Theresa, pick your name. You know, number one risk to you is heart disease. And we have a program here to screen you for heart disease. And maybe around age 45 will start every 5 to 7 years. And we're going to do a test that was developed in 1998. University of California, San Francisco called a heart calcium CT scan. And we're going. To do that. The clock comes back zero. We're going to celebrate with a nice big salad with sunflower seeds and pumpkin seeds and balsamic on it.

And if it doesn't come back zero, we're going to focus like all our efforts on identifying why you aren't a coronary artery, calcium c d score of zero, and we're going to try and prevent it from accelerating over time. And should you run into breast cancer disease issues, we're going to have to really overlap the supportive care for your breast cancer issue and your silent heart disease issue. So this was a CT scan developed 1990. At the time it was introduced in the United States, it was about 1500 dollars out of pocket.

The insurance companies weren't sure what to do with it. Functionally, you're on a stretcher. You go in a circle CT scanner, no I.D., no injection, no iodine. You hold your breath and you go home about 5 seconds later, without a Band-Aid, without any claustrophobia, the radiation exposure is less than a mammogram. It's a CT scan, but it's a very quick on and off CT scan. And there's a software that says zero, no calcium in your heart arteries. You have incredibly good prognosis for probably a decade, but you might want to repeat that test in 5 to 7 years.

And if you are anything over a zero from one to 11 to 142, and there's just literally there's no way, of course, everybody should know blood pressure, blood sugar, blood cholesterol, smoking history, diet history, grandparents, parents, brothers, sisters, the whole gamut. Put those all into calculators and you come up with some prediction that you might have heart disease. When you do the CT scan, you change two thirds of those numbers. Some people judged to be low risk way up, some people judged to be high risk come out of perfect zero.

And it's an enormous peace of mind not to go off and eat donuts and sit on the couch, but to celebrate. I'm not getting heart disease. I'm 64. I'm a zero. I want to stay as zero. I'll periodically retest and a lot of my lifestyle is about keeping the healthiest arteries I can because there's probably no better metric of your overall health and aging. And there's all kinds of aging tests. Now, there's other doctors out there. I'm 20 years old, 20 years younger than my birthdate,

Coronary Calcium CT Screening Explained 11:40

and it's because of all that I've done well, they all missed the boat because if their calcium score is zero, they're young. And if their calcium score is outside of the range, they're not young. I don't care what your epigenetic or your glycan test and your till telomerase test. Of your. Skin, you need a heart artery aging test. So get a coronary artery, calcium CT scan or a heart artery calcium CT scan. In my city that caused between 50 to 99 bucks you pay out of pocket. And every 5 to 7 years, essentially, everybody can afford that.

And it's just a glaring, glaring missing piece of the puzzle. And you go back to the thousand people a day that drop dead without a chance to kiss their loved one goodbye, 80% of them, at least, could have been picked up. This is known data on a CT scan three months, six months, three years, and could have had a program with aspirin and diet and exercise and medication. In a recent study like really reason out of Copenhagen, Denmark, where they took healthy people, men and women. Half of the study was women, which I always love to see.

9500 element unusual. 50% had a calcium score over zero. That's pretty much the cut. You're 50% likely right now to have silent heart disease. And over the next years ahead, it was eight, nine, ten times the risk of having a heart attack if you weren't a zero. So you just got to get it done and you got to take care of your heart the way you get screened for other important, usually cancer based situations. What's the false negative rate with that test? Meaning like how many zeros ever end up having cardiac events.

Has been studied a lot of it's out of the same city of Copenhagen, but other places, ten years, probably less than 1%. You get your 99% likely ten years after a zero score to say, I've never been in an emergency room, I exercise and feel great and I've never had a stent or a heart attack. Whereas if you come back 100 or 300 or 500 or whatever, it's it's a much different number. It might be 20% rather than under 1%. And these are scientifically studied numbers. The American Heart Association took a long time, but they're pretty much on board to say this is a screening test for the masses.

And the two immediate implications are somebody listening right now. Their gynecologist, their internist said, you know, your cholesterol is 235. I think you ought to go on Lipitor and 20 milligram. The science is overwhelming. If you come back, calcium score of zero, you have no benefit from statin prescription medication like Crestor and Lipitor. So even the American Heart Association, a very stodgy group, says calcium score zero doesn't need prescription drugs for cholesterol needs. You know, eat a few sunflower seeds, pumpkin seeds, a little organic tofu and a big salad every day with oatmeal for breakfast.

Just manage it. So let me ask you something. The test is 30 years on the market, right? It is 50 to $99. It is incredibly sensitive and specific. Right. Why isn't it being universally done? Good question. What am I missing. After watching your entire summit and learning everybody's should then go over to Netflix and watch a documentary called The Widowmaker movie. It's probably now about five years old. It's the history of this CT scan and a little bit of a conspiracy theory, because I think you have to imply I mean, follow the money.

Well, there's no money in this test. So you're not going to get anybody from a hospital really marketing? I've seen it on billboards at times. It's just tragic. I mean, you know, the health care system, I'm not a big basher of the health care system. God knows I'm outside of it and I'm not part of it. And I'm proud to have a different view about it all. But, you know, they're going to promote the proton beam scanner that you use to treat prostate cancer and the new robotic surgery for heart surgery.

I mean, that's what you're going to see promoted. So sadly, there's just nobody but, you know, 50 of us in the country that talk about this non stop and get it done and none of us I don't own a CT scanner. I have zero conflict talking about this. Yeah so this is my cynical side saying is the issue that if you do that you will eliminate a large part of the population. That would be consumers of surgery, consumers of stat. And as consumers of, you know, they're spending I forget what the number is.

Is it $8 billion to. No, I'm sorry, it's $800,000 to brain or no. $8 million to bring a drug to market, but $8 billion return on investment, something like that. By about 800 million to bring a new cardiac drug to market and, you know, open. An 8 billion in return. You know, it worked really well for OxyContin. So they're all trying to get the scope, the real the real evil is. And again, there's a lot of good doctors and a lot of good medicine is, you know, you're 50 years old and you ask your internist, no, dad had a bypass at age 54.

What should I do? And all right, you ask your friend, the cardiologist, and they they they're going to say, yeah, let's go schedule a stress test for you. And I used to be a specialty called a nuclear cardiologist. You're on the treadmill and you have an I.V. and you get injected with something we used to call thallium and now we call cardio like it's radioactive. And you get the good news, you know, Bob or Jane, your stress test looks good. You can still have a horrible calcium score and totally missed about that.

You have silent heart disease because your arteries are aging, but they're not severely narrowed. That is a $2,000 test. And here we got a $50 test. Which one is going to be used more by some clinics and some hospitals and some administrators? And finally, the radiation dose of that stress nuclear test is 15 times higher than the CT scan. So you can get one every five years for 75 years and have the same radiation to your body, which we all should be concerned about, is one stress nuclear treadmill test.

I don't order stress nuclear treadmill test. I used to be an author on multiple well known papers on it. I just say no to abusive radiation doses and I don't consider the heart to be at all abusive. In fact, the levels are dropping so low with modern CT scanners, it's fantastic that we can do this so safely. Yeah. Yeah, that's amazing. So I have long since said that with the Mammographic screening program that started in 1970 with the best of intentions, but it was predicated on an understanding that breast cancer grows in a linear fashion and reaches some critical size, at which time, if you found it before that size, you could treat it early and prevent metastasis.

All right. And we've had several iterations of what the mammogram is, unfortunately, that that premise is incorrect. And breast cancer is a biologic disease that behaves biologically. So it is what it is from the beginning. It's growth is not linear or predictable. Well, and as we've had these different iterations of mammogram, we've become more and more sensitive. But we've also become more and more radiation delivering. So the original studies from 1970 that were considered a safe amount of radiation exposure error is no longer true.

With the 3D mammogram or the CT tomography. We are delivering three times the amount of radiation to women year after year after year, and a lot of these women are getting radiated twice a year now, setting that issue aside, we are picking up lesions smaller and smaller, and we're treating these women aggressively. We're treating them all aggressively. We're treating them with surgery, we're treating them with radiation. We're treating them with chemotherapy. We're treating them with hormonal blockade.

And for a lot of these women who were already probably going to get heart disease if they continued on the same trajectory, we have really accelerated that process for people and so I've long argued that the medical system is contributing to cardiac deaths

Why Heart Screening Is Underused 21:00

in the way that we treat breast cancer. So I'd like you to address that a little bit, talk about the effects of radiation on the heart, talk about the effects of chemotherapy on the heart, and talk about the the effects of hormone blockade. An excellent topic. I want to just add one pearl to the idea of women listening to the summit and the idea that I've never heard of or never had a heart calcium CT scan. And I'm going to go ask my internist, most states you do need a prescription. I ordered so many of them.

I have a pre stand prescription pad C, D, Kelsey, go to contrast and I've ordered, you know, tens of thousands of these. My wife's hairdresser has had it done. Her husband's had had done the nail, ladies had it done. Now ladies husband is done. I'll give these out to anybody. Well, and and quite frankly, I mean while we're, while we're talking about that a mammogram costs $150 if you're paying for it out of pocket. So a mammogram, which people wouldn't think of not getting a mammogram, and yet the the threat the exponential threat to life is cardiac disease.

Right. Right. The pearl I wanted to share before your very good question about, you know, risk of radiation and chemo is many women listening might already have encountered the breast cancer diagnosis and they may have had a chest CT scan, very common. Or maybe they had a chest CT scan because they had coded or their chest scan because they had an abnormal x ray, a nodule, if not a chest x ray. But if you've had a chest CT scan in the last two or three years, a good radiology should have sat on the report.

A competent up to date radiologist, no coronary artery calcification, noted or moderate coronary artery calcification or severe coronary artery calcification noted. It's it's the same heart in the same blood vessels that we're doing on the special dedicated heart. C D So I find this free information by going through in my new patients their hospital records. And if I see a Jessie D, I'm going to read the report. And if the report doesn't mention I know how or if I have the capability of getting the c d to look at the heart part of it.

And very often we don't have to order that special c d I can say, ma'am, great news. Trust me, I've looked at thousands of these. You have no calcium in your heart arteries three months ago. We don't have to order the $75 test and we save them radiation. So that's a little tidbit for everybody to consider when. And if they have had that study and it is not mentioned. Can they go back to the radiologist and ask them to re review it? Challenging thing to do, but absolutely. And I wouldn't do it if it's five years old.

But if you've in the last two or three months had a CT scan. Yes, absolutely you can. So, you know, you might have to go through the hospital operator. I can do it easier than the patient and pick up the phone. And sometimes I can't get my hands on the disk. So I have to do that. I have to leave an email to somebody at the Mayo Clinic and say, Could you please come? And I'd rather than, you know, I'd rather do that than expose a woman or a man to another dose of radiation for the heck of it. So you bring up a great, great topic.

And let's just start with radiation, because here's a woman diagnosed with left breast cancer and after maybe surgery and maybe some chemotherapy, the idea is that we're going to finish this off with radiotherapy, you know, and you're talking to an expert and I emphasize I picked left breast. It turns out that even with the best shielding and care under your left breast, it's your heart. And on top of your heart are your three heart arteries, coronary artery disease. That's where people get atherosclerosis, stents, bypass.

And there's absolutely unequivocal data that a woman who undergoes typical left breast radiation therapy as a post cancer treatment what? Not immediately, but months to years. Statistically now every woman should live till 90 without a problem. But statistic only there's more disease in the left and tiered ascending artery, the front widowmaker artery particularly that can develop. You know, you might get by without it. There's always new innovations to try and prevent it. Many women during their breast cancer treatment are doing very deep breath holds, trying by lowering the breathing muscle, the diaphragm to also lower the heart and get it out of the way of the radiation therapy.

It's something that is challenging but can be done and it's obviously safe. It's just a breath. So not only would it be wise for any woman to get a heart calcium CT scan once and maybe every 5 to 7 years after or a woman diagnosed with breast cancer recently, she's probably going to get a CT scan of the chest. So get somebody to read it. But a year or two, after completing all the therapy, if it involved left breast radiation might be wise to talk to somebody and and get another calcium score down the road.

I wouldn't you know, it takes a while for atherosclerosis to develop hardening arteries, but there's study after study after study about a higher risk heart disease and and the consequences are heart disease. Like actually heart attacks and all. That's that's one thing. Then you mentioned therapy. Before that topic. I want to mention that last month there was a study published and I think I can't remember which journal it was in. And they looked at radiation and there is maybe a difference. A Statistically or a statistical difference in local recurrence, but there is no difference in survival between women that that get radiation and women that don't get radiation.

Breast Cancer Treatment and Cardiac Risk 27:40

And I think given the fact that we know that radiation will accelerate heart disease, I do think that as a medical community, we may need to rethink the appropriateness of radiation, especially in older women, especially in older women. If there's no survival advantage, it just simply doesn't make sense. Okay. I agree. I and I also wanted to ask you if if someone did have radiation, don't you think that would automatically especially lopsided radiation? Don't you think that would automatically warrant a cardiac evaluation just because of the of the possible that.

Cardiology is called into breast cancer management issues? Number one, sometimes it's just standard what we call surgical clearance. Maybe that woman is older and has a history of heart disease, bypass stents, congestive heart failure, arrhythmia on a blood thinner. So we will be called in at times like we might be for a gallbladder or hip replacement surgery. Number two is the one you just mentioned, the radiation therapy. And number three is the chemotherapy and the hormonal modulation therapy.

So I wanted to be sure to say this and I'll say it now. A specialty has evolved in the last ten years, authentic specialty called cardio oncology. The tremendous overlap between cancer diagnosis, cancer therapy and heart complications. So you go to Mayo Clinic, Cleveland Clinic, University of Michigan, Johns Hopkins, wherever you mention they'll have a division of cardio oncology, usually a group effort, a team that involves could be gynecologist, could be gynecologic oncologist, could be oncology and hematology, and cardiologists that have dedicated their knowledge and experience to this.

And it's not necessarily every cardiologist. I've attended several national meetings called the first annual cardio oncology American College of Cardiology Conference, and now it's more than the first annual they progressing on. There's many of them. So I think that's actually exciting and good and I don't think it's super well known. I still end up educating my patient. You know, you probably would benefit from contacting the University of Michigan Cardio Oncology Clinic, and they go up there and they get really expert opinions.

Why is that important? We talked about radiation therapy. We talk about the fact that probably a woman undergoing cancer evaluation therapy should get some cardiovascular risk assessment before, during and certainly in the long term, after the cancer therapy. But the therapy itself, besides radiation and I'll just run through this just for time, but there's always been a famous chemotherapy class of drugs called Anthracyclines and Donna Roberson doxorubicin, and they're dosed very carefully, but they're very effective in various breast cancers.

And unfortunately, we know that at the higher doses, they can cause a weakening of the heart muscle. So we've shifted from talking about heart arteries to the very measurement of the V-8 engine function of the heart. I'm in Detroit, so we got to make car analogies. Are the V-8 engine and Anthracycline chemotherapy like Doxorubicin can weaken the heart, and unfortunately it's a permanent weakening. And that leads to a condition called congestive heart failure. So we monitor women getting that class of chemotherapy with ultra sound of the heart that's called echocardiograms, maybe with blood tests, a hormone called BNP and heart enzymes called troponin.

We like to pick up the problem as early as possible. There's some and the dosing is the main thing. There's some interest in certain medications that are heart failure medicines that are actually pretty widely available and safe to help prevent the permanent damage that occurs. But there have been some women that are permanently impaired and even died from a weakening of the heart called cardiomyopathy from the chemotherapy they're getting. There's a popular group of chemotherapy related drugs called her to receptor antagonists like Herceptin and very commonly used.

And they fortunately can cause the same weakening of the heart. But it's not irreversible and it's not permanent in the majority of women. It's not fortunate that it happens at all. So we go through the same process of monitoring the heart, obviously educating women about shortness of breath, ankle swelling, sudden weight fluctuations, all kind of classic signs and symptoms of congestive heart failure, but hopefully picking up a very subtle drop in heart function early, unfortunately. So that woman might mean lowering or eliminating the dose of that drug completely.

Then we get to, you know, in very just an overview, hormonal therapy, a woman completes her breast cancer therapy and gets told you're going to spend five years on Tamoxifen or other agents in that class. And there are some implications of interfering with estrogen pathways in terms of cholesterol levels, in terms of normal artery function. And that woman just needs to follow in adhered to a healthier cardiovascular support lifestyle, the diet, the sleep, the weight, the blood pressure, the blood sugar, the exercise and all.

And then there are those ones that are called aromatase inhibitors, like rim addicts or Anastrozole. They've actually been shown they're commonly used after breast cancer therapy is longer term plays, postmenopausal women and they may actually slightly increase the risk of actually a heart attack. So, you know, if your calcium score zero and your cholesterol's not 350 and some other measurements you should have done your risk for all those therapies are probably very low, but you want to walk into these treatments with as much cardiovascular information as possible.

I, I will. SATURNO, what you have in your clinic, but we do have in Detroit some naturopathic dogs. So they're not M.D. their knees and have actually gotten board certified in oncology and are of great assistance to women in diet and supplement sense and sleep and stress management. And I refer to them also as part of a team to wrap a whole lot of attention about women going through this traumatic period in their life. Yeah. And along with the aromatase inhibitors and we you talked a little bit about metabolic health and I have long said that cancer, not all cancers, but most cancers and certainly breast cancer is a metabolic disease.

And in the same vein, so is heart disease. Right. And so we see the risk factors. And you started to say this in the beginning, the risk factors are essentially the same. So for the same people that are getting a breast cancer diagnosis that are then in a position to have declining heart health because of exposure is how much is their metabolic state coming into play for you and what are your recommendations around that? Yeah, it's a big deal, of course. You know, hopefully the cancer diagnosis, the cancer therapy and the follow up therapies have been successful as they are in the majority of women.

I mean, for 90% of women who get breast cancer diagnosis, survive that breast cancer diagnosis, unfortunately, only to go on and die of heart disease. Right. There's there's that risk. There's a very shocking observation in several papers that seems to be true. Okay. You got the good news. You ring the bell at the end of your therapy, maybe a rang the bell at the end of five years, you're coming off your Tamoxifen and the team you're dealing with, you know, gives you a very optimistic long term look at your breast cancer outcome.

There are women that actually experience a heart attack in the follow up after completed breast cancer therapy suddenly spike their risk of having recurrence of breast cancer, you know that they're on this very low recurrence curve that spikes up. And there's been quite a bit of talk about, you know, heart of heart attacks is the immune system, things like macrophage white blood cells and neutrophils, white blood cells and natural killer cells and all these fancy names. And they're there is altered immune function after a heart attack and it may alter the actual surveillance going on in the body for, you know, a strange cell.

It's around and it may allow one to sneak through the system and start to grow. So that's not to scare people, but it is actually, I think, scary data. A woman surviving breast cancer ought to have the attitude of, okay, I survive that one, but a cat has nine lives and most humans don't. I'm going to get control. So now this cardio oncology approach has been described very succinctly as women should follow A, B, C, D, E and A is the awareness of the risk of heart disease in breast cancer survivors.

And we've talked about that the other day is aspirin, but aspirin is for women with the high calcium score on the CT scan, not all women need aspirin. If you're calcium score zero, it's been shown you don't need it be is blood pressure get a home blood pressure unit. Don't put it in the closet. Put it on the end table and use your home blood pressure unit. That's B. C is two things. And I just ask you, how often should people be checking their blood pressure? Because we obviously don't want them to check too much because that alone can probably raise blood pressure.

I would say do it frequently for two weeks. The best way to check blood pressure is sitting relaxed three times in a row. Even physicians me sits down to check my blood pressure, the velcro, the noise, the pressure. Blood pressure, number one is higher. The number two is higher than number three. So you do it about a minute apart and you really pay attention. And number three, and if you do that about ten times in a row, ten days in a row, any time of the day, and they're 120 over 70. Okay, maybe once a month.

Remember, once a month, the first of every month. Check your blood pressure. That's the B, the C is cholesterol and CIGARETS I don't smoke and not everybody needs to be on a cholesterol lowering medicine. I want to tell you a little tidbit that I just saw in the news today. But if your calcium score isn't zero,

Cardio-Oncology and Monitoring During Therapy 39:20

if your cousin scores zero, you can be rather relaxed in your attitude about your cholesterol, according to data, again, often out of Copenhagen. But if your calcium score is anything over zero, you want to work through diet, through fitness, through supplements and maybe even medication. Get your cholesterol in control, don't smoke. There's a bunch of things. Diet, eat healthy. I'm a whole food plant based advocate. I think it's the best diet for breast cancer. Big advocate and friend of Christy Funk in Los Angeles and her approach with Whole Foods land based and I'm sure you favor a whole lot of brightly colored, whole food choices.

A D is for the dose of chemotherapy. Just being aware that while we talked about the anthracycline and chemotherapy and then finally D is for diabetes, you know, being aware that we are having a legitimate we overuse the word epidemic, but an epidemic of pre-diabetes and diabetes as your doctor can I get a fasting blood sugar of fasting insulin I'm fasting him a globe and a1c3 month blood sugar and eating to avoid diabetes. Can I ask you about that? Because fasting insulins are not routinely checked.

Right. Why is that? You know, we and in abnormal fasting glucose is are not followed up on you know and a bad thing glucose of 112 is not normal and it might be overt diabetes or pre-diabetes. If you check the hemoglobin A1 C criteria, it just depends and a precedence and it maybe it hasn't been proven financially that if you take a thousand people and go beyond their fasting glucose and also check their fancy and then of course, the idea is you might have a mild elevation in fasting glucose, but your fast insulin is really quite high because your body is like a little duck in the water trying.

To keep up with it. Right. And keep up and try and keep your fasting glucose reasonably closer to normal. Less than 85 would be kind of an ideal fasting blood sugar now. And if your insulin is high, you are insulin resistant. That's one definition of it. If your hemoglobin C is over 5.6%, a simple blood test, you're undoubtedly insulin resistant like so many people. And it's all reversible with fitness and diet and supplements. And I'm really, truly reversible in days like these things. Just these things don't take a long time to reverse.

But you can do the same thing over and over and over again and expect a different outcome. Stop putting that butter in your coffee and that cheese in your sample, then your insulin resistance pretty quickly. And the last two hour E we went through ABCD e is for exercise of course benefits in every aspect of her life and E is about that technical test called an echocardiogram, which is what you do during the chemotherapy phase to monitor the heart. Now, if I were to redo this American Heart Association, I would have three CS cholesterol cigarets CT scan, and maybe when they're updated they'll listen to me and include that in the strategy to identify the earliest form of asymptomatic, silent heart disease.

There is an interesting report this week in our medical literature. There's always new stuff that patients getting these anthracycline chemotherapy like Donna Roberson and doxorubicin that happen to be on a statin had better heart function than those not on is that it's an observation it was about less inflammation less oxidative stress. We'll have to have trials in the future. We took women undergoing chemotherapy and we put some and low dose statin and some not on low this that I'm not the biggest advocate of using statins but it was in the news today and we obviously always got to keep open minded about new and innovative ways to.

Ensure. The health of women, even if it runs contrary to what we might do in some or other practice patterns. Know and you know, we know that statins do have an anti-inflammatory effect, which is largely, I think, why we see some benefit with them. But there are a lot less harmful things that have an anti-inflammatory effect that we could probably accomplish the same thing. Broccoli. Broccoli would be on. Yeah, exactly. Or turmeric. So. So let's say that you are someone who is out from treatment.

Is that the same person that should be getting a calcium score? You know, they were treated ten years ago or is that where they start? Yeah, I think living life without a calcium score is like living life without a seatbelt or texting while you're driving. Yeah, you might get through. Okay. But when we're talking 50% of people on good well done. Prospective studies without symptoms have silent heart disease is not optimal. So, I mean, you should plan your life. Okay. I got through that breast cancer scare. I feel good.

I look good. I'm back in the game alive, thank God. But you should, you know, plan number two. I don't want to be a heart victim. Wouldn't that be a sad state of affairs? And I think we've outlined you know, it's not all about that test, but I'm trying to be efficient. If you have that test and it comes back zero, most of your metabolism is working well for you. And if you have that test and it comes back 268, you need to see a preventive doctor and get advanced labs. And I'm telling you again, it's not about how you look outside.

I have husbands and wives that come to my clinic. And he came here from McDonald's carrying the bag and hasn't seen the inside of a gym. And she's the Pilates, yoga and fitness expert of the world and her size four dress. And she has got the high calcium score and he's got the zero. And, you know, you could, in a bet on a roulette wheel that that was going to happen. You have to test I use a hashtag all the time you mentioned social media test not guess your target heart disease. We're not looking for rare and obscure diagnoses.

We're talking the core risk that we all have, whether we have breast cancer or not. So husbands are women significant, others are women partners. Women with breast cancer should get a heart calcium CT scan. They're going to be under a lot of stress during their period to me. Absolutely. And let's just review again for anyone who has a calcium score of greater than zero, right? Anyone greater than zero, what kinds of things? It it is reversible right. There are they might get the. Calcium scored down, but you can stop the plaque from building up and building up. Yes.

And so and so what are those measures that you are talking to people about that that work to stop heart disease and maybe even reverse it? I mean, we do talk about that all the time over reversal of heart disease. Science is there. You can reverse heart disease. So the number one, you want to get the blood pressure cuff. I just want to give that a shout out again. The 80 to 100 million Americans are walking around with high blood pressure. Another silent disease, a silent killer. And you want to get treatment for number two.

You want really extensive labs. You want to get the ones your internist or family doctor does you want if your calcium score is not zero, you want to know that diabetes aspect, the fasting insulin, the hemoglobin, A1, C you want to know you mentioned inflammation, your C-reactive protein blood test, the special one called the high sensitivity C-reactive protein, and you want to know a panel, I think of some genetic tests. The most important one is a version of cholesterol called light bulb protein,

Metabolic Health, Prevention, and Reversal 47:40

little AA or LP, little AA 20 to 25% of all the women listening to this summit inherited from mom, dad or both the ability to make two kinds of cholesterol. It's enough. We make one in excess. We don't need do. The second one is called light bulb protein little AA. You haven't heard much about it because you haven't read my book and there are no pharmaceuticals to educate your doctor to check it routinely for $30. But you probably want to get it checked if your calcium score isn't zero and find out if you have inherited from the moment you were conceived.

A double whammy ability to make too much cholesterol and too much lipoprotein cholesterol. You know, I like. Something that is also improved with diet and lifestyle or is that is what it is. It may take supplements, particularly niacin and it's not statins. Things like Lipitor increased are lower routine cholesterol. They don't lower lipoprotein cholesterol, which is why there are a lot of ongoing studies right now and we're close to 2 to 3 years away from having pharmaceutical agents, but I can get lipoprotein a down.

It turns out a woman finishing menopause who adopts hormone replacement therapy. If she's a woman who inherited lipoprotein a, it keeps the levels low. If she adopts maybe bioidentical or more standard hormone replacement therapy, that's scientific mission. That's not the same woman who's had breast cancer. She's got to work on hormonal therapy with her team. And it may, in fact, be the opposite. You know, estrogen blocking may potentially raise lipoprotein levels. Which is usually what happens.

And for anyone who's had breast cancer and is in this position, there is an Excel book written by Abrahams Looming called Estrogen Matters. I love that book. It's sitting five feet from me and I show it all the time. Yeah, it's an amazing book. It is a must read for any woman. And he really addresses the issue of hormone replacement in the breast cancer population. And because I don't know about you, but I finished my training in 2002, the year that the Women's Health Initiative was released. So in the end, irony of my career, until I read that book, I was under the impression that having had a history of breast cancer was an absolute contraindication to hormone replacement.

And even without a history of breast cancer, when we gave people hormone replacement, we gave them the short that the least amount for the shortest period of time. And since 2002, I think we went from almost 50% of women being on hormone replacement in the in the post menopausal setting to somewhere around 6%. And I wonder what impact that has had on cardiac disease, because it is protective. Right, right. By, uh, I am a fan of advising my patients get excellent evaluation and excellent counseling on the topic and that is the same book Estrogen Matters I think about 2018.

So you'll find it in paperback at a low cost and everybody to read it couldn't agree more. Yeah. So has what what have you seen in terms of practice? Has that increased the amount of cardiac disease or are we seeing it at an average younger age because women aren't going on hormone replacement? I think it's a component. I mean, we're talking about women age 50, 55 and up, you know, and at the same time, we've got more pressure on our diet. We have dealt with smoking pretty well. We haven't dealt with blood pressure.

We haven't dealt with early detection. I think it's a component, but we're still dealing with so many people, you know, uninformed or not choosing to eat well, exercise well. And, you know, the data is in less than 5% of Americans actually eat according to kind of hard prevention protocols. So we got that big thing. We've got the hormonal thing. We've got a lot to work on. Yeah. So you're talking to people who have a calcium score of greater than zero about checking blood pressure, checking labs.

You're obviously talking to them about and and there are some genetic variations with LP little a but they do get better when you put all these other dietary and lifestyle things into place, right? Absolutely. You know, in 1990, Dean Ornish, M.D., published a book called Doctor Ornish His Plan for Reversing Heart Disease. I mean, he didn't have an acid trip even though he was living in San Francisco. There was a lot of that going on. He had research and in a randomized studies and careful and geography before the time we had there, like sneaking some broccoli and doing work in your life using fasting protocols.

I'm a big fan of L nutrients five day fasting mimicking diet called Braylon. We use a lot of that in my clinic. People can really deal with five days of fasting programs and then enjoy the rest of the month and help manage their weight very quickly. I think I think you, all of us froze for a little bit when you started to talk about Dean Ornish. So will you just back up a little bit and talk about you were saying that, you know, it's not as if he didn't have technology available to him. Right. And yet he came out with this protocol.

Was I made a little joke about the fact he was close to Haight-Ashbury and it wasn't an acid trip that he wrote a book called Reversing Heart Disease. It was carefully and well done randomized clinical trials in humans that he was such a pioneer along with Nathan Friedkin and others. So we know you can shrink. BLACK Well, you don't you don't always get worse and worse and worse. We can get better and better and better. We may not take arteries that are disease to make them perfectly normal again, but you absolutely can.

And it's, you know, managing your diet and it's a whole food plant based diet. It's managing your fitness. It's managing your sleep. We know now that fragmented and short sleep, sleep apnea contributes to heart disease dramatically. And finally, we're learning more and more that, you know, I like science based fasting protocols like Dr. Valter Longo's five day fasting mimicking diet. In fact, I'm doing that right now. This week I'm on day two and feel wonderful. Yeah, yeah. It's really amazing. We actually his research was in breast cancer and with women undergoing chemotherapy and so I employ that with all of my patients going through a treatment because it makes a huge difference in terms of not only response to treatment, but also it protects the normal cells.

Right? So they don't need as many factors and they have energy and feel great and and all of that. And so his work has been really, really important in this in this arena. But I love I love ProLon and I and I love the five day fast. And it's really it's remarkable how great you feel when you give your body arrest from food. Right. It's from another. Concept because we eat, you know, 2 to 4 times a day, day after day, after day. And, you know, it takes discipline. But Dr. Longo has given us this.

I call it a gift. Just open the box and do the instructions and don't negotiate it and don't break it. And you'll probably lose four, five, six, seven, eight pounds in five days and feel good and promote, you know, self-renewal and regeneration and a cellular level. Quite remarkable. Yeah. Yeah, it really is amazing. Is there anything else that you want to say before we wrap up? I think that what we've covered here is so important, the fact that that cardiac disease starting in the 30's is at least twice the threat to women's lives.

And then I think when you get up to 70, it's like seven times the amount. So we are losing expend more lives to cardiac disease than we are to breast cancer and yet we're not talking about it in the same way and it really needs to be a part of the conversation, not only because cardiac disease is the threat to life, but that once you go through breast cancer, the the treatments for breast cancer actually accelerate cardiac disease. And it's really the same thing at the root of both diseases. It is absolutely.

It is. Absolutely. You know, dietary and stress and mental drama and sleep issues and inflammation. And there's a lot of commonalities. So, you know, the good news is get your lifestyle in order, figure it out, get a good doctor like you and work with them. And you can tackle many, many illnesses at once and prevent many illnesses with one game plan. Broccoli and turmeric. Yeah, absolutely. And, you know, at the end of the day, just like I'm sure you say, like heart health is heart health and breast health is health and we're all one system.

And so the things that you do to protect one system protects the entire system and the things that you talk about, the whole food plant based diet and movement and prioritizing sleep and managing stress and yeah. And making sure that you are being proactive about your health because really at the end of the day, there's no doctor that's going to be able to save you. Right? The only person that could save you is you agree? Well said. Yeah. It was wonderful to have you here. I so appreciate your time and your experience and your persistence.

You can't say no. I am. I'm I am persistent and I will continue to stalk you on social media because I love what you have to say. And thank you so much for sharing your gift with the world. It's it's so important. And people need to hear voices like yours. Oh, thank you so much. Appreciate it. Good luck. Thank you. Bye for now.