Passion Struck with John R. Miles - Dr. Michael Pishvaian on Why Hope Is the Key to Fighting Pancreatic Cancer EP 225

Episode Date: December 8, 2022

Johns Hopkins gastrointestinal oncologist Dr. Michael Pishvaian joins us with special guest host Carolyn Miles (John's sister) to examine advances in pancreatic cancer diagnosis and treatment. They discuss why hope is the key to fighting pancreatic cancer, and this interview gives you some tips on how and where to find it.  What I Discuss with Dr. Michael Pishvaian About Advances in Pancreatic Cancer Diagnosis and Treatment In this episode of Passion Struck, Dr. Pishvaian, John, and Carolyn Miles discuss the latest advances in pancreatic cancer diagnosis and treatment, including clinical trial therapies, early detection, and biomarker research. They share their insights on finding hope in the face of this deadly disease. Carolyn is a pancreatic cancer survivor and brings her personal experience with the disease to help ask the critical questions that pancreatic cancer patients need to know about. Topics covered include currently available pancreatic cancer therapies,  alternative health treatments, the most promising research, biomarker-directed therapy, immunotherapy, clinical trials, diet, medical marijuana, homeopathic, and new pancreatic cancer research. Dr. Pishvaian also talks about biomarker research and how it is helping to identify pancreatic cancer earlier.  If you're searching for hope in the face of pancreatic cancer, then this episode is for you.  Full show notes and resources on Pancreatic Cancer can be found here: https://passionstruck.com/dr-michael-pishvaian-fighting-pancreatic-cancer/  Brought to you by POM Wonderful, Shopify, and Omaha Steaks. --► For information about advertisers and promo codes, go to: https://passionstruck.com/deals/  --► Prefer to watch this interview: https://youtu.be/_smxqyY8xdc  Like this show? Please leave us a review here -- even one sentence helps! Consider including your Twitter or Instagram handle so we can thank you personally! --► Subscribe to Our YouTube Channel Here: https://www.youtube.com/c/JohnRMiles Want to find your purpose in life? I provide my six simple steps to achieving it - passionstruck.com/5-simple-steps-to-find-your-passion-in-life/ Did you hear my interview with Robin Sharma, one of the top personal mastery and leadership coaches in the world and a multiple-time number-one New York Times best-selling author? Catch up with episode 209: Robin Sharma on Why Changing the World Starts by Changing Ourselves ===== FOLLOW ON THE SOCIALS ===== * Instagram: https://www.instagram.com/passion_struck_podcast * Gear: https://www.zazzle.com/store/passion_sruck_podcast Learn more about John: https://johnrmiles.com/ 

Coming up next on the Passion Struct podcast. I think the most promise in the next three to five years for Panthers Cancer specifically is going to be in biomarker directed therapy, meaning that there's a specific genetic or molecular alteration within the tumor that's been identified that leads to specific therapy. And there are multiple such biomarkers that can exist in Panthers Cancer's if we go looking for them. Welcome to PassionStruct. Hi, I'm your host, John Armiles, and on the show, we decipher the

secrets, tips, and guidance of the world's most inspiring people and turn their wisdom into practical advice for you and those around you. Our mission is to help you unlock the power of intentionality so that you can become the best version of yourself. If you're new to the show, I offer advice and answer listener questions on Fridays. We have long form interviews the rest of the week with guest-ranging from astronauts to authors, CEOs, creators, innovators, scientists, military leaders, visionaries, and athletes. Now, let's go out there and become PassionStruck.

Hello, everyone, and welcome back to episode 225 of PassionStruck. Recently ranked over the past month is one of the top 20 health podcasts. And thank you to each and every one of you for coming back weekly to listen and learn, and to live better, be better, and impact the world. If you're new to the show, thank you so much for being here. Or if you would just like to introduce this to a friend or family member, we now have episode starter packs, which are collections of our fans, favorite episodes that we organize in a convenient topic.

To give any new listener a great way to get acquainted to everything we do here on the show, just go to passionstruck.com slash starter packs or Spotify to get started. In case you missed my episode from Burler in the Week, it featured Dr. Alyssa Hallerman, who's a psychologist and author of the brand new book, Sobriety, where she discusses, how do you overcome trauma, breed addiction, but more importantly, reconnect to your inner soul. I also wanted to thank the community for your continued support by giving us five star ratings and reviews.

They go such a long way in helping promote the popularity of this podcast, but more importantly, growing the passion star community. I also know that our guests love to read your messages as well. Now, let's talk about today's episode. Pancreatic cancer is the third leading cause of cancer-related deaths in the United States behind lung and colon cancer. Often, the symptoms of pancreatic cancer are imperceptible at the early stages,

leading to a large number of cases, not being caught in time. Today, we will be discussing all things pancreatic cancer with Dr. Michael Pishvan, one of the world's leading gastrointestinal oncologists, who specializes in pancreatic and refractory colorectal cancers. He will explain how there are now several biomarkers that are helping doctors as well as patients in the early testing and diagnosis of pancreatic cancer. We will go into why if patients are diagnosed

in time for surgery, their chances of surviving five years or more increases to end-fold. We will also be discussing in-depth the treatment options for pancreatic cancer, which includes surgery, radiation therapy, chemotherapy, immunotherapy, natural path options, homeopathic options, as well as the role that diet plays. Dr. Pischvian is the director of Gastrointestinal Developmental Therapeutics and Clinical Research Programs

for the Johns Hopkins Himal Cancer Center, as well as being an associate professor at the School of Medicine. He is committed to precision medicine and provides his patients with the most appropriate as well as advanced level of care. He provides all levels of clinical trials for all GI cancers and enrolls qualifying patients. We are also joined today by a special guest host,

my sister Carolyn Miles. Carolyn is a licensed master social worker, providing individual, group, and couples therapy, as well as being a pancreatic cancer survivor. Thank you for choosing PassionStruck and choosing me to be your host and guide on your journey for creating an intentional life. Now let that journey begin. I am honored today to have Dr. Michael Pishvian as well as my sister Carolyn on the Passion Struck podcast. Welcome to both of you. Thanks so much. Well for the listener, you know, I've mentioned my sister in the past, but this is the first time that she's been on the show. I thought before we started asking my questions that she could tell a little bit about her story and what led us here.

Yes, hi, my name is Carolyn Miles and Dr. Pishvayan is a dear source of hope, I'd say, for me, and has been since the beginning when my oncologist here in Austin, Texas connected me to him. So I was diagnosed in September 2020, shock of all shocks, because I am an extraordinarily healthy human being, always eight right, exercise four to five times a week, really took care of myself, and there's no genetic

link to pancreatic cancer in my family. What I heard at MD Anderson was this is really bad luck. You just got really bad luck. I was originally diagnosed with stage two pancreatic cancer right before I was about to have the major life saving surgery, they thought my cancer had spread to my liver. And this man here, Dr. Pishmayan gave me hope, said, I see, I've seen a couple patients who they thought the scans showed it was spreading to the liver, but it didn't. You keep pushing and pushing and liver, everything disappeared. So I was able to have the life saving with full surgery at MD Anderson. And then tangentially on either side, I had eight months of chemotherapy, largely full fear and ox, which is one of the mainline treatments.

I've had a year of remission, a little bit over a year of remission, a little bit over year of remission. In fast forward, I just learned five weeks ago that my cancer is back and it's misnassified to my lungs. Now, I know I face a terminal cancer, but I want to live as long as I can because I'm darned, I want to get my son through high school, which is a six year target. So I need to be an outlier to the statistics. So that's my story. Carolyn, thank you for sharing that and if a listener might not have any clue what

Whipple's surgery is, can you just give an explanation of what that is to them? I'm happy to dive into that. It really takes a lot of courage to walk through your history like that. So calmly, it is really transformational to one's life. You have to be struck with this. And there's some things that you said that I really want to emphasize. One of which is that you have a cancer diagnosis now with the cancer having spread to the lungs. That means it's something that's curable, but I don't like to use the word terminal

because you're not going to spend the next hopefully six or more years or have much time you have left just waiting for the end. You're gonna make the most out of life that you have left. And so I think of it as just another part of the travails of our life that we have to deal with. And that's why I really like the hashtag for the World Cancer Day was hashtag, it's about time, which I think is really appropriate.

It's really about just how do we of course extend the life of people in your situation, but do so in a way that it's maximizing their quality life so that they can live as close to normally as possible. And I think that should really be the aim and the goal. As for what a whip of surgery is, so it's a surgery that removes typically the head of the pancreas, which is the one that's closer to the middle of the abdomen. And because the head of the pancreas, the blood supply and the weightings connect, the surgeon when they remove it, they obligatorily remove the first part of the sphondestin.

They used to also remove part of the stomach, but that's not really the case anymore. So it's just the first part of the spawn test and they used to also remove part of the stomach, but that's not really the case anymore. It's just the first part of the spawn test and it dewaed them. And then they reconfigure the plumbing a little bit so that the stomach empties directly down into the part of the intestine that's a little further down. The flow of food doesn't go quite as smoothly from stomach to doodan as it does now from stomach to the other part of the small intestine. The Whipple Surgery is a major surgery. Most patients spend at least five to seven days in the hospital afterwards and another six to eight weeks at home recovering and even people who are cured of their cancer or any other condition for which they had the Whle, it often is described as something that's life changing,

but something that you can learn to get used to and it all contains a couple of years to learn to reconfigure how you lead, how you lead your life to be able to get used to having had a whiple surgery. Just for completion, the other surgery that we do for Pangress Cancer is called a distal pancreatctomy. It's actually a simpler surgery. It's usually done laparoscopic now just by cameras and probes where they remove the tail of the pancreas. Again, because the blood supplies are all connected,

they also removed the steam in a bilgatory way. Thank you for that, Anne. I thought maybe we could just take a little bit of a step back and maybe just give the audience a better understanding for what led you to go down this path of becoming a gastrointestinal oncologist. Sure. Happy to. I'm trying to make the long story short, but when I was in medical school, I did a PhD

in cancer research and primarily the folks was on breast cancer research, but actually as I came into residency and started to focus my clinical pathway, I just had incredible mentors in the GI cancer world, and of course it wasn't a small factor that my wife is gastroenterologist. So we were speaking the same language, but I just felt like in the

GI cancer world, there was so much progress that needed to be made, not that there's not in many other cancer types. But when I graduated residency, it was 2004. Fellowship was 2007. And we have made so much progress in the world of death and intestinal cancers, including pancreatic cancer in the last 15 years, but where we were 15 years ago, wow, it was a tough time. And I just saw the need was so great in this field of GI cancer research. Well, I just recently read earlier today that pancreatic cancers, the second leading cause of cancer related deaths in the United States. And I wanted to understand what makes pancreatic cancer different and more difficult to treat than other types of cancer. Yeah, I wish I knew that clear answer to that question,

but you're right, it is definitely a very deadly cancer. Part of it starts from the outset. What if Haker's cancer develops at the earliest of stages, it learns to sow these microscopic seeds of cancer. And we know that because even patients who have a Whipple or other surgery to remove a very early stage cancer, they're still unfortunate, decent chance that cancer will reveal itself a couple of years later because those microscopic seeds were sown early on.

Above and beyond the fact that it has these microscopic seeds, it's just a cancer that's also fairly refractory to chemotherapy. Chemotherapy helps in things like cancer, but it doesn't cure cancers. It doesn't make them go away completely. Some of the other cancers we might treat with chemotherapy. And then it also has a fairly rapid use

of developing resistance to the chemotherapies that we do have. So the longevity of being able to successfully use a chemotherapy is unfortunately relatively short. The Pagradi cancer also suffers from not having had much of an opportunity to respond to immunotherapy. So, immune targeting drugs have been really revolutionary in the last 10, 15 years and melanoma of the skin was as bad as pain risk cancer 15 years ago. But for some reason, well, we know why. For many reasons, melanoma responds robustly to immune therapies that trigger the immune system to try and fight cancer directly. We haven't had that success in pancreatic cancer. There's a lot of internal mechanisms

by which pancreatic cancer tumors, not just the cancer cells themselves, but all of the tumor and what surrounds the cancer cells creates an environment that really suppresses the immune system. And we haven't learned, we globally, haven't really learned how to overcome that degree of resistance.

And the final comment I'll make about why Pekkaide Cancer has not been successfully treated is because these cancers traditionally were not thought to harbor a lot of genetically targetable biomarkers. But I think we're learning that that's changing, and we're starting to understand better some of the drivers, and there are newer therapies being targeted towards those drivers. Okay, and I'm going to direct this question at both of you. I also understand that PC is very difficult to detect early stage at times. And Carolyn, I remember right before this happened with you, you were at her parents' house feeling fine and then all of a sudden something started to change and you noticed subtle

changes. For someone who doesn't understand this, I was hoping you both could talk about it. I could just start with the personal story. I was feeling fine. Although I would say looking back now, I remember for years increasingly saying how tired I was feeling all the time. And I just thought it was because I'm a single mom. I was working full-time, getting my masters in social work in my spare time. So I was just like, oh, it's because I have too much going on. But no, I think it's because the tumors were making me tired. But the real signs were when I started having nausea, we just couldn't figure out what it was.

And then the blood work showed the belly ribbon and liver scores were really high. And so they did a stat MRI. But it was really the nausea, the exhaustion. And at the very end, right before the diagnosis, I would need to take two naps a day. So it got increasingly worse and then I got jaundice and itchy all over my body. Yeah, what you experienced was not uncommon to take this cancer. The pain is itself sits in the middle of the abdomen. It's actually a relatively soft organ and something that grows there doesn't tend to cause

much in a way of problems until often it's grown enough to cause big problems. So most patients who are diagnosed with pain-grade cancer have very vague symptoms. They get down a little discomfort, maybe not even pain, they acknowledge a tiredness. Sometimes they're losing weight. There's a lot of patients that have been trying to lose weight for 20 years and then all of a sudden

they're happy that they lost 10 or 20 pounds whereas really it was because of the underlying cancer. I think that we as a community just need to stay vigilant to some of these potential symptoms because there's no real red flag symptom and there's no screening test for pancreas cancer. Only about 10% of patients present in the classical way that you did where there was actual jaundice, actually yelling of the eyes, the darkening of the urine that develops. And again, in those situations like in your situation symptoms have probably been present for weeks, if not actually in months. And then the other part of it, the pancreas tumors are hard to diagnose.

So there's countless patients that I've seen that have gone to see that primary care doctor and they've had endoscopies, they've had cat skins that weren't done quite the right way, not that they were wrong, but they weren't looking specifically for a pancreatic tumor. And they were just missed. The gold standard test to be at identified, PAKERS-MAS, is an endoscopic ultrasound, which is obviously an invasive procedure, and not something that we should do for every patient who has a little bit of a dominant discomfort. If in the future, we start to develop true screening tests for pancreatic cancer, that could make a huge impact on his disease. screening test for pancreatic cancer, that could make a huge impact on this disease. And just a follow on to that, are you finding there to be any difference in discovering

it between the use of a CT versus an MRI? So there's a CT, there's a way to do a CT called a pancreas protocol CT that is fairly universal across most centers where it's not really about the quality of the scanner. It's really about the way in which the contrast is injected and then how quickly the pictures are taken. A radiology department just needs to be aware that that's what they're looking for. Most CTs that are done for somebody who's in the emergency room, they aren't done that way. MRIs, they might be a little bit better, but they're not night and day different, night and day better. And even MRIs, and sometimes

miss pancreatic tumors, a good quality, pancreas protocol CT, sometimes can be better than an MRI. Okay, and you mentioned several of the treatment options already you both did. You've covered the two different types of surgeries. Just for someone who may not understand what is the typical theme of therapy and radiation protocol that's used. Sure. Well, before I go to that, let me just real quick mention that only about 10% of tumors that are diagnosed with the pancreas are diagnosed as awful from the outset. And what really defines operability is what are the chances that the tumor is going to be gotten rid of entirely, but there's actually a true potential for cure. Because the tumor can always be removed by a surgeon, but

a surgeon leaves tumor behind or if there's tumor that's already spread to other organs, then this big operation isn't going to do the patient any good. So that's really what I mean by operability. It's not the technical ability to go in there and get the tumor out, but will it achieve the goal of intended to be cured in therapy, a cure to surgery or not? So 10% patients have truly awful disease. Another 30 to 35% have disease that is localized within the area of the pancreas, but maybe wraps itself around some critical blood vessels, making the chances of leaving cancer behind, and then unfortunately more than half of patients diagnosed already have cancer that has spread to other organs. state of treatment for pancreatic cancer is really chemotherapy because even for patients who have curative surgery, their cancer still has a high potential to come back and we

know that giving chemotherapy can reduce that risk. Not unfortunate to not to 0% these cancers still have a decent chance to come back even with chemotherapy, but we've improved the odds overall. Do you want me to go into the details of the kinds of chemotherapy that we have? Maybe just quickly, because I know we want to just spend a good chunk talking about things beyond this, but yes. So basically there's two cocktails that we use. One is a three drug cocktail called full phyrinox, made up of three drugs.

Five FU, Irinity, Can and Neufsauflat, and care on that's the kind of you had. The second drug cocktail we have is called Gem-Sightedine and Nampacate Paxil. And these two cocktails really are our foundation. They both work to some degree. We don't really know which patient benefits from which cocktail better,

and some of it is just trial and error. They both can have side effects that we just need to be ready to adjust and tweak and make the changes that we need to make it tolerable for patients. But they both have improved outcomes significantly compared to 12 years ago where our only standard of care was a single drug called gymsitidine, which really didn't work very well by itself. How do you use radiation therapy as part of this protocol? Radiation therapy frustratingly has never been proven

to help cure patients with pancreatic cancer, cure more patients with pancreatic cancer. And there have been dozens and dozens of trials trying to figure out how to optimize the use of radiation, but we've just never proven that it actually makes a difference. Now, having said that, we often use it. So, one of the things radiation does do very well is control symptoms, control pain, discomfort, other things that are coming from these hard pancreatic tumors that are shooting in the pancreas. And I will not

infrequently send my patients to radiation therapy for the purposes of palliation of helping them to feel better. There's a real controversy in the literature as to whether we're making tumors more operable by offering radiation therapy. Again, many of us still continue to do it, although the

published literature would probably suggest that we shouldn't, but that's a whole nother debate. This is the PassionStark podcast with our guest, Dr. Michael Pishvin. We'll be right back. This episode is sponsored in part by Shopify. Hear that little chit-ching? That's the satisfying sound of another sale on Shopify. The all-in-one commerce platform trusted by millions of entrepreneurs to create their online store. Shopify is a platform designed for anyone to sell anywhere,

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our sponsors because they're the ones that keep the show going as well. You can check out all the sponsors at passionstruck.com slash deals. You'll find all the codes and URLs, all those things are there. So please consider supporting those who support this show. Now back to my conversation with Dr. Michael Pishman. Okay, and if you're someone who might be facing this

and you've gotten this diagnosis, I know one of the things that we went through is, how do you find which hospital or which physicians are best to treat you depending on what has been discovered? What would be your advice to patients about that? Pegas cancer is a complicated disease. There are a lot of subtleties that come with experience. And so I think going to the center that sees a fair bit of pancreatic cancer is really important. There are resources out there including the pancreatic cancer action network has their patient central. They will guide patients to more active pancreatic cancer centers all across the country. So

that's a phone call that can be made. Yeah, that would be my primary thought. Okay, and Carolyn, I'll turn it over to you to ask a couple questions. I know you talked about the first line treatment, which is chemotherapy and then the wipple, but now I'm just in the dynamic where now I have metastatic pancreatic cancers. I'm starting the gym sata bean a brachsen again, but I am having to look ahead to clinical trials and I know this is your area of just expertise in the country. One of the challenges that I am struggling with is I know my biomarkers. I know you advocate for getting your biomarkers done, which foundation one did my testing. And so I know I have a very common mutations. I have Keras and I have that TP3, I think it's called. And so Keras is the leading one, which is the leading for people who have anticarcinoma, which is the most common type of thinker at a cancer.

So when you go to your institution, like I could go to MD Anderson, what they are going to offer me by way of clinical trials is what they have in house. So what I am perplexed with sometimes is I understand that but they have regionally in their hospital system. But given that I know my two biomarkers, I want to know what's the best clinical trial and if I need to go there for the clinical trial, I'll go there. But I'd rather it start with me, my pathology, my biomarkers leading me to the right trial as opposed to this local institution. This is what trials they have available. Yeah. and one that I really wished that there was a national solution for. So first of all, I'll say that yes, I agree 100% that every patient with pancreatic cancer should undergo germline genetic testing. That germline meaning that the genes that they were born with.

And we usually do that with a blood test or saliva test. And all of the guidelines support that we should be doing, that kind of testing on 100% of pancreatic cancer patients. In addition, the vast majority of meaning 80 to 90% of pancreatic cancer patients. In addition, the vast majority, meaning 80 to 90% of patients who have cancer that's spread, should also undergo tumor testing, what we call somatic testing. And there are institutional tests that can be done for that.

There are also retail labs like foundation medicine, carous, tempis, and many others that can do that test as well. Those tests are important because they may actually open the door to additional therapies including the concepts of clinical trials. So if a biomarker is identified, then it's a matter of how do we find those clinical trials. Again, there are some resources that can be used. There's clinicaltrials.gov, which is a very clunky resource to navigate that. The pancreatic cancer action that work,

I keep pointing towards them, they do have the ability to help patients search through trials that are geographically located. There are newer programs that are developing to try and navigate patients to a clinical trial that are nationally available. Unfortunately, a lot of it's just word of mouth. The one thing I would say is,

at least in the academic pancreatic cancer community, we tend to know each other very well. We're all very good friends. It's a very friendly community. And if you went to your medical oncologist and the Anderson said, hey, is there another trial that you know about there? I know that he or she would have no qualms

about sending an email to our community, if you will, and say, hey, does anybody have a trial? I do that all the time. I'm on the East Coast, so I will routinely send an email when I have a patient who's willing to travel basically from my college from Boston down to North Carolina. And I always actually include the Indian folks as well, just because they're such a huge resource. So a lot of it, unfortunately, is worth a lot. I've always said we really need to have an actual navigation resource for getting patients on a clinical trial, depending on how far they're willing to travel for.

You asked me the question about the value of getting patients on clinical trials. Well, pancreas cancer, we know is a tough cancer to beat. And so any progress we could make is good progress. I think what really has to be weighed in very heavily are the goals of the patient. If you have a patient, like the one patient I had, who had his private jets and used to fly from Canada every day to come to me every other week for a clinical trial, then great. that was fine for his quality of life. But if you have a patient who really doesn't have the ability to travel that far, then we need to go and find the metrial

that's going to be within a reasonable distance to be able to get on that trial. And again, that's where navigation systems come to play. I think family and friends can also be big advocates. I've had many, many family members and friends of patients that have reached out to me and say, I encourage you might have a clinical trial, and I personally am more than happy to engage those patients

as are many of my colleagues around the country. I know that for sure. Well, that's really helpful and it is a clunky process. So I appreciate you validating that experience from the patient experience. Well, and then I know this is your area of expertise is like sourcing out clinical trials and looking at biomarkers. And so I am just wondering like sitting where I'm at, what novel treatments that are in phase one or phase two trials, should I be paying attention to? Are that your thinking are the most promising ones coming online?

Yeah. I think the most promise in the next 35 years for pancreas cancer specifically is going to be in biomarker directed therapy, meaning that there's a specific genetic or molecular alteration within the tumor that's been identified that leads to specific therapy. And there are multiple such biomarkers that can exist in tankers, cancers if we go looking for them. One thing I always emphasize for anybody that's listening to this is there's nothing about the patient usually that tells us that they actually have that genetic alteration, not even family history angle like that can necessarily be predicted. So, the physician just needs to go looking for these potential molecular alterations, including in what we call fusion genes, which are not detected on the traditional symbol of DNA panel, they usually require an RNA panel as well. And again, many of the retail testing labs are looking for these fusion genes now,

but you got to go looking for it, otherwise you'll never find it. As far as promising trials, I think a lot of them are targeted towards the biomarkers and the breadth of biomarkers that are being tested now is growing. Traditioning in the last side, take five to 10 years, we've been focusing in Pancras Cancer on microsatellite instability or mismatch repair deficiency, which can occur in any cancer type, occurs in about a half a percent of Pancras Cancer, so one in 200 patients. So not common, but there are trials for that population of patients. There are the DNA damage response and repair pathogenes, which is a mouthful, what we call DDR or HR, which is hemologous coronation.

Most people know it as the BRCA, one of the BRCA, two family of genes, bracket one, bracket two. It actually improves drug for that, called elapid for very specific subgroup of patients, but there are actually any trials trying to target this DNA response and repair pathway such as with back one or back a two.

And then there's other tests that are out there. There's new kids on the block, if you will. There's an NRG-1 infusion that occurs in about 1% of pancreatic cancers, and there's two new drugs that are looking very promising. One might even get FDA approval relatively soon. There are retesusions, which can occur, again rarely in pancreatic cancer, but when they're identified, they can actually make some pretty out-of-out impact for patients. In terms of the most common mutations, which are the K-RAS, K-RAS mutations, 90% of these pancreatic's harbor these K-RAS mutations.

Most of them right now are not targetable, but there are about 1% in tanker's cancer of K-RAS G12C, so very specific K-RAS mutation for which there are now very specific drugs that look very promising. But there are also newer drugs coming down the pipeline targeting the more common K-RAS subtypes, including K-RAS G the more common K-RAS subtypes, including K-RAS G12-D and K-RAS G12-D. We're actually about to open up a G-TW-D targeted study here hoping the next coming couple of months that we are very excited about. And I know that there's a similar trial in Indiana that would be very worthwhile considering as well.

So there are a lot of trials that are available. Some of them are not necessarily located at your quote unquote home institution, but I think being ready to look beyond can help a lot. And Carolyn, can I just ask a cool question here. On another podcast I heard you on and I might have this incorrect, but I thought you had indicated

that it was a large amount of patients once they've been diagnosed with bank-creatic cancer, the insurance record show that in many cases they're not treated. We all know that this gets extremely expensive. How do you work with the insurance community to ensure that you're getting access to the clinical trials that could save your life? So yeah, we actually, we looked at a huge insurance database and asked the very simple question, if you look at pancreatic cancer diagnostic codes, ICV-10 codes, and look to see what happened to those patients in terms of billing thereafter. 55% of patients who had a pancreatic cancer diagnosis never got any further therapy. Not surgery, radiation, chemotherapy, not even palliative care, which was really sad that we're not treating more than half our patients with pancreatic cancer across this country. And it's because there's tremendous cynicism about this disease, that it's a terminal disease, that you might as well go get your affairs in order or all of those kinds

of things. And they don't realize that we can actually help patients live longer and feel better when they have pancreatic cancer. As far as negotiating getting these patients in clinical trials, there's a law, there's a law in the books that says that if a patient is enrolled in a clinical trial, the insurance company is required to pay for everything that is typical and normal standard care insurance billable. So standard doctor visits, standard labs, standard CATs, those are all, it should be billable to insurance, of course, assuming the patient is assured. Things that are the costs that are born outside of the context of the clinical trial, as I understand, kind of the standard of care, need to be born by the clinical trial.

So either the person, the company who's paying for the study or the institution and things like that. And a lot of trials, especially for these very rare biomarkers subgroups, they can offer travel support, travel costs. There are also advocacy groups out there that are committed to helping patients travel to a site to be able to get on a clinical trial as well. Okay, Carolyn, did you have any further questions on that line? Well, I keep delving further and further in. So we talked about the first line

and the second line treatments, the chemo and then the clinical trials. And then Dr. Fishway and I'm curious too, if there are any non-medicals, so non chemo, non-radiation, non-surgical treatments or factors that you've seen patients employ that you think increases their longevity with metastatic disease. And we have some that are proven and the one that I would point to a ball ball house is simple activity or exercise. There was an amazing study presented at our June meeting, our ASCO meeting, done by the French,

where the patients were randomized to receive standard chemotherapy, both hearing aids, and for metastatic disease. And they were randomized to an engaged physical activities get program versus not. And these physical activity was nothing intense. It was 15 minutes of activity a day and then build up as tolerated.

And what was amazing for that trial is that patients who were engaged in activity lived four months longer than those who didn't have any activity at all, which doesn't seem like a lot, but it is in the world of metastatic pancreatic cancer. So I think programs that are really focused on encouraging physical activity

could be helpful while patients are getting their chemo therapy for the pancreas cancer. We know from the lung cancer literature and we've barred it to other cancers as well. I don't think we've proven it definitively in pancreatic cancer, but I'm sure it would be true that palliative care can actually really help patients live longer. There was a critical trial done, I think, now maybe three,

four years ago, for patients with advanced lung cancer, they were again randomized to start palliative care, palliative care means supportive care, pain control, aggressive nausea control, supportive measures to help the quality of life. But from the get-go, not at the end of life, from the outset of diagnosis, and patients who receive pallet of care, again, lived considerably longer than those who didn't receive pallet of care from the outset. So I think exercise of pallet of care are critical parts of any pancreatic cancer patients journey. There are other secondary things that I think are important as well. Things like acupuncture

have been proven to decrease nausea, perhaps decrease pain a little bit. Medical marijuana I'm actually a very strong proponent of only because I have seen it benefit probably 99.9 percent of my patients. I don't prescribe it because I don't really know what I'm prescribing, but I refer patients to dispensary so that they can get guidance there. But I'd say almost all of my patients benefit in terms of nausea, increased appetite, decreased pain when they start using medical marijuana. And can I ask just one follow on question to that? There's one type of medical marijuana that is often talked about in the cannabis community and that's RSO or RIC Simpson oil,

which people claim has cured them of cancer have you ever had any patient who has used that, who has had a positive result from it? Not specifically, a little skeptical of the medical cannabis claims to cure or treat the cancer. I think they do a great job in supporting the patient's symptoms, but I think that we just have improved in any kind of a formal clinical trial that it actually helps improve cure rates or survival or otherwise. Because he's not controlled enough

that I can do any kind of a clinical trial that's regulated, I can't really say, oh, this is the formulation that's the best. I can only tell you based on experience. Now, I treat a lot of pain and cancer patients. So what I hear is, I hear a lot. And what I've heard generally is that patients benefit more from things that are like animals rather than the CBD oils that might be used.

But that's not based on data or science just based on lots of anecdotes. Okay. And I did want to keep going down this thread because I know one of the other things that I've often read can have an impact is diet. And I think it's widely known that sugar can just aggravate the situation. I know in Carolyn's case, she has gone to an extremely clean, mostly plant-based diet. I don't know if you want to expand on that, Carolyn, but my question to you would be how have you found diet, I guess, mixed in with treatment plans? This has been in big Odyssey trying to find out what to eat because when you go through treatment, you're

basically told we just need you to have enough calories. You already lose like 30 to 40 pounds going through the surgery. And so right now it's me wanting to absolutely make sure I keep the weight on. I can't lose any more weight. I've been recommended and there's some evidence based trial showing that ketogenic diets are beneficial for pancreatic cancer. So I've gone to an extreme, I completely gave up sugar, and then didn't realize that things like dates, figs, fruits, or causing glucose spikes, which could have an impact on pancreatic disease.

So keto is the way I think I'm gonna go right now. Yeah, I think there are some promising science out there, including keto diets that may be a benefit. There is a clinical trial, I think maybe as you're alluding to ongoing right now, trying to ask the question, chemo plus a keto diet versus chemo alone will it improve survival?

We don't technically know the answer to that yet, but I'm very supportive of anything that's going to enhance the healthy lifestyle while anything that's going to enhance the healthy lifestyle while the patient's going through pancreatic cancer treatment. But, and there's a very big buzz, which is that patients also just need to get their calories. And if they're not able to keep up their chloric intake,

and we know that pancreatic cancer is a very high caloric intake disease and a very catabolic disease. And so the patients need a lot of calories to be able to keep up. And if they just can't keep up their calories they need by switching to a plant or otherwise based diets, then I think that they have to stick to just a more traditional diet. If there were my preference, yes, it would be a healthier diet, but I'd rather they eat something rather than nothing at all in a least a way.

As far as sugar, specifically, sugar is a tricky one because there's some really fascinating laboratory-based research where if you keep the sugar levels very low in the milieu and in the sort of dish that the cancer cells are living in, that they become much more susceptible to chemotherapy. The problem is that to get to that level where the sugar is so low because our bodies regulate our blood sugar so closely, we would virtually be in a coma.

And so we can't get our blood sugar levels as low as it needs to be to replicate those studies that have been done in the laboratory. So it's a tough decision. Again, I tell patients that I'd rather you eat a healthier diet, but if you can't stomach, no pun intended, if you can't stomach a healthy diet and you can really just eat fairly bland foods that are not, quote, unquote, a metatranian diet, then I think it's best just to get the calories in. To that end, there are some really great nutritionists that are out there.

There's not enough of them. We need, we as a society need to do a lot better, much better job supporting nutritionists as a career and supporting their job, but some of them are fantastic and really guide patients through the kinds of things that they need to eat to keep their calories up and yet to try and stay healthy as we've just been talking about. Thank you, because that's definitely a tricky thing. You get so many recommendations on what or what not to eat.

And after a whipple, you can't go raw. You can't do a raw plant diet. But, and then another thing that's been real promising is complementing chemo or, yeah, it's usually chemo and radiation protocol with things like vitamin C, infusion. There have also been some promising trials and even Von Haugh who invented Jim Sattabin,

he's leading two of the trials. So, curious what you think of that. Again, I think that unfortunately none of these things are proven, but I also don't want to stand in the way of them at all. Thankfully, by the in-scene fusion specifically, don't seem to add anything in the way of side effects. They definitely add cost. And so, I worry a little bit when patients are going to, sorry, a holistic dog and getting charged a lot of money for them to see infusions when we don't actually know that it benefits them.

But at the same time, medically, I haven't seen that it necessarily cost anything in the way of side effects. I'm really happy that some of these trials are being done and pursued so that we can get to a final answer. And the answer might not be necessarily what the community wants. There was a really big study done recently that came out.

It's not for cancer, well, not for pancreatic cancer, but it was looking to see if a multivitamin reduced heart disease or reduced the incidence of cancer. And the long and short of it was it did not it so that was the big hit in the gut of the vitamins supplementation communities say that we don't really need these vitamins so I think these studies should be done and they should be done properly in the way of the patients who wants to get some of these holistic medications outside of my practice I'm all for it except unless there's any worry that it's going to actually hurt them. And something like vitamin D, there's no proof that it hurts them. High-dose vitamin D, by contrast, there's a real mixed story to that. There's been some studies

that have suggested that it helps chemo, particularly gem-sidony and base chemo, but then also some studies that suggest that it hurts it. So I hesitate a little bit with the vitamin D. Other turmeric, I think there's no clear evidence that it hurts, so I have no problem with it. But mushroom extracts, there are reports of fatal liver failure from mushroom extracts that can occur in combination with chemotherapy. So I think everything has to be taking very carefully.

There are integrated medicine centers that are integrated into medical oncology communities and I think those are great to work with. We actually don't wonder how one here where I work but nearby at George Washington University there's a great integrated medicine center and I'm happy to work with the team there because they very much are thinking about the chemotherapy and oncology perspective. What I do worry about are some of the purely holistic physicians, even in my area, who don't communicate with me at all and don't really take into consideration the drugs that I'm giving my patients as well. And then how about homeopathic treatments or natural pathoc treatments. I've read literature about things, quite a call,

debalogalium phase, taking a deep detox regimen with homeopathic drops because toxicity in the body can lead to spreading cancer, et cetera. This is probably something that you haven't studied, but again, is

this something where you haven't seen any negative consequences from it? Yeah, I think the, I think you hit the name on the head is it's not something that you haven't studied, but again, is this something where you haven't seen any negative consequences from it? Yeah, I think the, I think you hit the nail on the head is it's not something that I've studied. It's not something that anybody's studied. There are no publications on this that exist at all. And that's my only, that's my main objection.

No, I have not seen any negative consequences other than the financial toxicities, which in some cases can be quite significant. So I worry that patients are getting, I don't want to say fleece, that's too harsh a word, but I worry that the patient that's committing their life savings or more financial resources than they really can afford to for some of these methods that have been completely unproven. If they can be proven and they are proven to help, and I always put the acupuncture as a perfect example,

a study was done that clearly showed that acupuncture helped decrease nausea and pain and other side effects. And I'm happy to encourage patients to go to acupuncture and because of the proof that was established, insurance will often pay for active function. So I think that's the direction that we really need to push our homeopathic community to go into is to do proper clinical trials so that we can justify having our patients get those therapies and push the insurance companies to pay for those therapies.

companies to pay for those therapies. Okay, and I just wanted to revisit immunotherapy on another podcast. I heard you say that its effectiveness in pancreatic cancer has been less than one percent if I have it correct. But are there centers around the world that are aggressively looking at this and doing any trials with it that might show some hope for its use. Yeah, there's dozens and dozens, so it's important to kind of walk through the progression. So 10 years ago, there were single agents, single drug immunotherapy, so the anti-PD1 or PDO1 agents like Nevolumab and Hebalismab and other agents like Ipiluminem, those drugs by themselves, the response rate,

the benefit rate was literally 0%. It didn't help anybody. And there are side effects to these drugs that sometimes can be quite severe, it's not common, but even a 3% to 5% rate of serious side effects is far worse than a 0% benefit. But we also know that immunotherapy works. I mean, Dr. Allison

got the Nobel Prize for very good reason because it really does work in certain kinds of cancers. The only question is, how do you make it work for pancreatic cancer? What is the nut that needs to be cracked or the glass ceiling that needs to be broken to finally make immunotherapy work? And I think that we're getting closer and closer to that glass ceiling. I'll give a nod to my colleagues up in Baltimore and Johns Hopkins were doing amazing sequential research, adding more and more therapies to decrease the resistance to immunotherapy so that hopefully you can start

to finally work for patients with any gradic cancer. Because of that, there are literally dozens and dozens of trials that are ongoing all throughout the country, all throughout the world that are trying to make immunotherapy work. Finally, once and for all, for pancreatic cancer, incorporating vaccines and incorporating what we call cell-based therapies, I would never

have in a bad of an eye, I'd be happy to refer a patient like that to a clinical trial. What I would not do, though, is knowing that the single drugs don't work is I wouldn't take a patient like Carolyn and say, okay, we're going to be done with chemotherapy and now we're just going to prescribe pemblyzina, which is called contrude. Because that by itself won't work. I would be happy for her to be enrolled in a clinical trial of pemblyzina plus x, y, and z in the hopes that those extra agents are going to help.

Okay, thank you for that. And then, are there risk factors that people might be doing in their life that can make the occurrence of pancreatic cancer more prevalent? And is that something that you've been able to tie anything to? I think the community is really still scratching your heads and what really causes pancreatic cancer. There is an association with overweight, diabetes, insulin resistance, and maybe it's an increased risk, well definitely an increased risk

in that population of patients. But it's not a black and white risk factor factor the way I think of smoking and lung cancer as a black and white risk factor. So yes, we all should actually strive more to do more exercise, lose more weight, eat healthier, and those steps alone probably will decrease the incidence of pancreatic cancer, but I'm not sure that they'll massively decrease the incidence the way that we would hope it would. There are, however, there are about seven to ten percent of patients who have an underlying genetic alteration over the decades of life, leads to pancreatic cancer, and there's where testing more of those patients, where finding more family members and harbor those

mutations, and there's some really exciting data that putting them in a proper screen program can significantly improve the curate. For example, the curate and I don't use that term lightly, I really mean cure, the curate in a patient population who's been screened and yet despite being screened they've developed the cancer, they still have a curate that's probably about 80 percent, which is way higher than we typically see for the sort of typical pancreatic cancer who walks in the doctor's office. Okay, thank you. And Carolyn, did you have any last questions? Well, one big one I have is I think you're the hope doctor every time I listen to your

podcasts or even have interacted with you on the phone, you give me hope. Sitting where I'm sitting now and wanting to believe that it's possible that I can live a lot longer. Like what hope should I have? Why should I have hope? That's a really tough question. I think the answer is that you should have hope that your team, your doctors are gonna try and help you to live the best life that you can for as long as you can. There's definitely an acceleration in the pace of research in Pancras Cancer, specifically, but in the cancer community in general.

And so the goal really is to keep you on treatment until something else comes up and then try that. And then again, so the next thing comes up and give that a try. And there are resources that are being developed across the country to get patients to that next level of trial. Okay, so it's like the trial to trial to trial

and just can't just hope it's something, almost like the lottery that something has. I just spent five minutes talking about the fact that immunotherapy doesn't work, but I gotta tell you that my colleagues have been Baltimore who run lots and lots of immunotherapy trials for tankers cancer. They tell me that there's not many patients, but they've got a handful of tanker out of cancer patients that are probably close to cured of their cancer, if not, frankly, cured of their cancer because of the trial that they have to go on. Why those patients

benefited truly nobody knows, even the doctors running a trial don't understand why, but it happens once and a while. And so you just hope that you're gonna be lucky enough for benefit to that degree. Yeah. And then really thinking outside the box, I'd love to talk you offline when it's more appropriate, but there was a clinical trial that I had wanted to get started in the innocent that I just heard that my colleague

Alice notion of in New York opened up for pancreatic cancer that has spread to the liver that I'm super excited about. And I think just that word of math about hearing what to build on what options are our gets people, again, more hope, but hope of other options to treat their cancer. gets people again more hope, but hope of other options to treat their cancer. Well, thank you so much. And thank you for being just a nationally profound being willing to speak in forums like this because you really do lead us to paths that we might not consider as patients. So I've certainly benefited from your advice and counsel.

I really appreciate that. I mean, everything. that it from your advice and counsel. I really appreciate that. I mean, you've got to be able to. When I'm certainly humbled that you were able to come on today and Carolyn, thank you. I can't imagine what it would be like if I were in your shoes trying to do this podcast. So thank you for the way that you've handled it

and the confidence and hope and everything that you've displayed throughout the past few years. It's been truly remarkable. If there was someone in the audience who wanted to learn more about you and what you're doing at Johns Hopkins, what is the best way for them to connect with you? For me personally, I can't speak to all of my colleagues, but they're more than welcome to see you, you know know me. So you want to share my email and I have no problem with that at all. Okay well great well thank you so much and thank you Carolyn for being on the show as well. You're welcome thanks thanks just Dr. Pich Ryan. I wanted to thank Dr. Michael Pich van

as well as my sister Carolyn for joining us today's very important episode. I also wanted to thank John Hopkins for giving us the honor for having him here on the show. Links to all things Dr. Pishvin and my sister will be in the show notes at www.AshianStrek.com. Videos of today's episode are on YouTube, both at JohnRMiles, as well as our new Cliffs channel, which is called Ash and Struck Cliffs. Advertiser deals and discount codes are in one convenient place at passionstruck.com slash deals. Please consider supporting those who support the show. I'm at John Armiles, both on Twitter and Instagram,

and you can also find me on LinkedIn. You're about to hear a preview of the PassionStruck podcast interview I did with Dr. Jonah Berger, who is a professor at the Wharton School of the University of Pennsylvania, an internationally-claim best-sellingselling author and an expert on change, word of mouth, viral marketing, social influence, and how products, ideas, and behaviors catch on. And we will be discussing his newest book, The Catalyst.

How do you change anyone's mind? That's exactly a great catalyst, dude. They don't push hard. They identify those roadblocks and they mitigate them, right? They figure out, well, why is that person unwilling to change? Or how can I rather than feel like pushing, help people see that they can actually choose the outcome that they want? Regardless of what you're doing, regardless of your big organization, a small one, a for-profit, a nonprofit, these barriers come up again and again, and I think the more we understand them, the more we can be effective at changing minds and driving action.

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