Re-purposed drugs from an Oncologist

The core component of being an Integrative Oncologist involves how I collaborate with patients and their loved ones in the management of their cancer. In many cases, it is straightforward. I am listening and guiding patients on the treatment of their cancer and how it integrates into their lives and lifestyle.

We work together to flush out personalized risks and benefits of treatment so they can live with side effects, uncertainties, and logistics of cancer care. In a majority of these cases, the role of exercise, nutrition and using holistic modalities to treat symptoms (acupuncture, yoga, meditation) comes into the collaboration. See more on acupuncture and cancer.

We discuss supplements. A supplement system from an oncologist.

We discuss end of life. Read about my idea for Code Silver.

We get into it.

There are rare and rewarding cases that go beyond and live on an edge of true understanding, mutual respect, and collaboration. These are special cases that jolt me back to life. I understand these truly collaborative relationships as feelings rather than a set of rules and regulations.

Ayo is a woman in her 30’s diagnosed last year with localized triple negative breast cancer with BRCA mutation. She has aggressive breast cancer on her maternal side, and she lost her mother to metastatic disease as a child.

She has a PhD in biochemistry. At the time of her diagnosis and throughout her treatment, she lived alone, two oceans away from her family. In addition to navigating her cancer treatment, she managed the rigors of advanced education, unfamiliar cultural norms, and social isolation.

Her cancer presented with a palpable lump. She was quickly started on chemotherapy and immunotherapy but felt the mass continued to grow. Pointing it out to her surgeon, she was examined but reassured it was likely cell break down and inflammation. Weeks later, with continued questioning on her part, imaging showed the mass had doubled in size at which point she was taken directly to surgery.

She had residual disease at surgery. Radiation, more chemotherapy and immunotherapy were advised. She remained on hormone injections that shut down her ovaries to protect fertility. After the additional chemotherapy and immunotherapy, oral medication, a PARP inhibitor, was suggested for 2 years. Her reconstruction was delayed. She did everything without question. She felt like garbage. Her life was suspended in a fog of fatigue and “cancer-ness.”

The first time I met her, for an integrative oncology consult, her poise and grace knocked me sideways. She was distressed but spoke with measured calm. She described twists, turns, and self-described “communication blocks” with her medical and surgical oncologists. For our visit, she had an objective in mind; she wanted to incorporate specific pharmaceuticals to target pathways to improve her odds of cure. This concept is known most generally as re-purposing.

Common drugs with familiar side effects, antibiotics, NSAIDS, statins for example, are viewed through a lens of cancer pathways. I’ve had patients bring up re-purposing before and I have deferred; this represents a more alternative approach than I am comfortable with. I’ve been open to hearing patients out and to observing and documenting if they pursue this through other means, but stopped short of prescribing the drugs.

Ayo had a folder with meticulous diagrams. As a biochemist, she had done deep personalized research on her cancer, triple negative with BRCA mutation. She understood the mechanisms of how the checkpoint inhibitor and PARP inhibitor targeted her biochemical pathways. She drew them out with arrows for where Metformin and Simvastatin would intervene. Her command of the science surpassed my own. I sat and listened. And as I listened, I felt a subtle shift; I was comfortable with this collaboration.

For the last year, I’ve prescribed her re-purposed drugs and monitored her labs and side effects. I’ve weighed in on her surveillance plan, the second opinions she has sought, her weight training and keto-like diet choice. I’ve applauded her new role as a post-doc in a medical genetics lab at our local academic cancer center. I care deeply about her and the feeling is mutual.

The pleasure and satisfaction I get from this deeper layer of my work as an integrative oncologist, or perhaps a medical oncologist that truly collaborates, has been a welcomed surprise. There is much that lives beyond standard evidence in oncology and statistics from randomized controlled trials. There is even more to explore by intentionally treating and learning from patients and their loved ones.

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