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The Role of the Microbiome in Oncology Care with Carla Wrenn · Wellness by Designs - Practitioner Podcast

• 0:20
  Speaker 1: This is Wellness by Designs, and I'm your host, andrew Whitfield-Cook, and joining us today is Carla Wren.
• 0:26
  Speaker 1: Carla has her own holistic assessment approach, called Vitae Mosaic, to provide each person with an individualised and integrative treatment strategy, and today we're going to be talking about gut health in oncology.
• 0:39
  Speaker 1: Welcome to Wellness by Designs, carla, and thank you so much for your time.
• 0:44
  Speaker 2: Thank you for having me.
• 0:46
  Speaker 1: It's my pleasure.
• 0:47
  Speaker 1: It's been a long time between, do I say drinks.
• 0:49
  Speaker 1: Anyway, Carla, gut health is such a huge brushstroke.
• 0:57
  Speaker 1: Where do we start with this when we're dealing with a patient who has an oncology diagnosis?
• 1:06
  Speaker 2: Yeah.
• 1:07
  Speaker 2: So my area of practice has been around supporting patients who have been diagnosed with cancer to help their whole health and their healing.
• 1:14
  Speaker 2: Lots of patients come to me and say what else can I do while I'm doing the treatment or after my treatment has finished?
• 1:21
  Speaker 2: And so, while I didn't initially set out to work in the gut health space, more and more research is coming out that really enforces the idea of we need to look at the microbiome of patients with a cancer diagnosis During the diagnosis stage, when treatment is happening, perhaps especially afterwards and maybe even beforehand, to reduce the risk of some diagnosis.
• 1:44
  Speaker 2: And I've just really been inspired by the volumes of researchers available and how we can start to use them in practice, because we know generally not in all cases, but generally a probiotic is a really safe intervention for people with what looks like really great outcomes from the research that's starting to come out.
• 2:04
  Speaker 1: Well, let's talk about that aspect that you mentioned there straight off the back safety.
• 2:08
  Speaker 1: So, firstly, we're not talking about treating cancer with gut health things.
• 2:14
  Speaker 1: We're talking about supporting the patient who has their own treatment regimen.
• 2:18
  Speaker 1: We're just making sure that they're healthy so that they're healthy enough to withstand that treatment regimen.
• 2:24
  Speaker 1: That's exactly right.
• 2:27
  Speaker 1: And the other point I was going to say is we might as well bring it up now instead of later with red flags, and that is that you know it's very rare in the research where you get an issue with a probiotic.
• 2:42
  Speaker 1: Can you cover those just straight off the bat so that we've got them out of the way?
• 2:47
  Speaker 2: Yeah, perfect.
• 2:48
  Speaker 2: So I guess with the issue with the probiotic, let's talk about that first, because often when people hear me talk they get into a big panic because we don't always want to use a probiotic in oncology and that really fits around when a patient is perhaps at risk of neutropenia.
• 3:17
  Speaker 2: So if a treatment they're on certain chemotherapies will cause the patient to experience a low white cell count or more specifically, neutropenia, which is a low number of neutrophils, and so if your treatment is going to give you neutropenia, you usually might have seen that as a kind of side effect of the treatment.
• 3:25
  Speaker 2: You usually might have seen that as a kind of side effect of the treatment.
• 3:27
  Speaker 2: But regular bloods are normally done through this process and patients when they're told a neutropenic they definitely don't want to be on probiotics.
• 3:31
  Speaker 2: It kind of comes back to something I always try and say get professional advice if you're on a whole lot of medications to make sure any supplements you take it doesn't have to be a probiotic.
• 3:42
  Speaker 2: Any supplement is safe.
• 3:43
  Speaker 2: But people like myself who are trained to support patients with complementary medicines know the guidelines.
• 3:50
  Speaker 2: It's loosely around if your neutrophils are under one or your white cell count is under 2.5, we don't prescribe probiotics.
• 4:00
  Speaker 1: What about things like, for instance it's noted in the literature Saccharomyces boulardii, where somebody's got a PICC line or a central line and the well-meaning nurse doses them with Saccharomyces?
• 4:13
  Speaker 1: Continue from there, carla, because I can see you smiling.
• 4:16
  Speaker 1: Yeah, 100%.
• 4:17
  Speaker 2: Yeah, definitely.
• 4:18
  Speaker 2: No one ever knows that information, so I love that you know that.
• 4:21
  Speaker 2: Yes, well, there's been a couple of cases where and remember, it's just a few cases, but where people have given themselves sepsis or have been given sepsis by Saccharomyces boulardii is one that I would very infrequently prescribe in oncology patients.
• 4:47
  Speaker 2: But just talking about the hygiene of managing the capsules as well, wash your hands.
• 4:51
  Speaker 2: If you have a peak line, don't touch it when you haven't washed your hands, whether or not you've used supplements.
• 4:57
  Speaker 2: And Saccharomyces boulardii is probably at the bottom of my probiotic list in terms of what I would use to treat patients during an active treatment phase.
• 5:08
  Speaker 1: Okay, cool, so take us through some of the issues that patients experience then.
• 5:15
  Speaker 2: With the probiotics.
• 5:17
  Speaker 1: Sorry, forgive me during their oncology journey.
• 5:22
  Speaker 2: Yeah, perfect.
• 5:22
  Speaker 2: So I guess we could take a step back even before that, and I think one of the interesting things to mention, just for future information that will be coming out, is they're really starting to see such strong patterns in the species that have been discovered in people with particular cancers.
• 5:36
  Speaker 2: A lot of research is done on the colorectal cancer space that patients are even starting to be able to potentially use microbiome patterning to determine what cancers they might be experiencing, almost like a screening tool.
• 5:50
  Speaker 2: So maybe we'll be sitting here in 10 years time or longer thinking, okay, we're going to go and get our fecal occult blood test, which is the standard test to look for maybe risk of colorectal cancer, and a microbiome test that says we're high in a few key species that are common in colorectal cancer.
• 6:06
  Speaker 2: So therefore we definitely should have further investigation.
• 6:08
  Speaker 2: So I love that idea and how that's starting to develop.
• 6:11
  Speaker 2: For lots of cancer types ovarian cancer, bladder cancers they're all starting to see these microbiome mappings for risk and maybe screening for these cancers.
• 6:21
  Speaker 2: But the next thing I see in my patients is coming with one of two things they want to do something to improve their health themselves, they want to know what they can do.
• 6:29
  Speaker 2: And then we think about okay, what are these integrative strategies that we can pull in to help support the patient as they go through their treatment, with their whole health, and probiotics fit really well there.
• 6:38
  Speaker 2: And then I also think we see a lot of patients coming in with side effects.
• 6:42
  Speaker 2: So they'll come in and they'll say I just can't cope with my diarrhea or constipation, as an example.
• 6:47
  Speaker 2: Fatigue is another really common symptoms that patient will come in while they're undergoing treatment and there's research to suggest that in some of those instances of course particularly with constipation and diarrhea, also with oral mucositis symptoms and a number of other symptoms that probiotics would be a really safe intervention, even after surgery.
• 7:08
  Speaker 2: There's some really great results that show that if we use probiotics seeded after surgery for colorectal cancer, the patient has far less complications with surgery and a greater recovery from that surgery.
• 7:22
  Speaker 1: Are there any specific species?
• 7:24
  Speaker 1: Or we could go into strains if you want to, because I know that everybody's thinking about one strain in particular.
• 7:30
  Speaker 1: But can we go into certain species, strains that you use, that feel comfortable and that's evidence-led?
• 7:38
  Speaker 2: Yes, look, I think the first step I would say is, before I even look at species and strains, is I'm thinking about what prebiotic fibers I can bring in because there is no risk in that prebiotic fiber space.
• 7:51
  Speaker 2: So I think sometimes, rather than jumping straight to the probiotic, I'm trying to change the environment and feed whatever's there before I maybe do a more risky is the wrong word, but a more interventional step of introducing a probiotic, particularly in their early stage of treatment.
• 8:07
  Speaker 2: So I always talk to every oncology patient about trying to get variety and diversity in their food, so aiming for 40 plant foods a week and I show them easy ways to do that and say how important that is for the microbiome and that kind of blows people's minds because it's an exciting thing Like normally we have a reputation as an industry of telling people what they can't eat.
• 8:27
  Speaker 2: So it's really exciting to say to them OK, I want you to go to the green grocer and buy all the weird fruit or all the different vegetables and really try and eat the rainbow and get more plants in.
• 8:38
  Speaker 2: And so I talk to them about herbs and spices and legumes and nuts and seeds and how all of these can be really helpful for their microbiome herbs and spices and legumes and nuts and seeds and how all these can be really helpful for their microbiome.
• 8:46
  Speaker 2: And then, particularly if they're constipated or if they're having trouble with their bowel motions and the health of them, I try and get some probiotic fiber in, and so for some people that's enough of an intervention.
• 8:56
  Speaker 2: Certainly from there I would be guided most in most cases by doing some stool testing.
• 9:02
  Speaker 2: And I actually have a colleague in my practice here at Peninsula Herbal Dispensary, amy Castle, who's a naturopath that has the certified gut training.
• 9:09
  Speaker 2: She's done a lot of extra gut training with people like Jason Holbrook and also Moira, so she will see a lot of my patients when it starts to get a bit more complex because, you would know, the gut is exploding overall in all this amazing information, and so I will usually then get some testing done.
• 9:27
  Speaker 2: But at that point we'll then decide what kind of strains and I'm looking at LGG as a number one one to think about.
• 9:33
  Speaker 2: But you know, a good low dose broad spectrum probiotic is also safe to use if we just follow those rules of watching what the white cell count is doing, watching what for neutropenia, and then using those prebiotic fibres and the food fibres as a basis for the intervention.
• 9:56
  Speaker 1: When we're talking about gut health.
• 9:57
  Speaker 1: Obviously you know stool health can vacillate between constipation to diarrhoea depending on treatment.
• 10:01
  Speaker 1: Stool health can vacillate between constipation to diarrhea depending on treatment, depending on anxiety, so many other things, even tumour effects, direct tumour effects.
• 10:10
  Speaker 1: So do you ever favour any sort of prebiotics where, in one dose it can be, it can help with constipation and in another dose it can actually help to bulk stool up to stop diarrhea, for instance?
• 10:29
  Speaker 2: Yes, definitely, and I really try and talk to the patients and educate them a lot about what to look for in a stool and all our different options in terms of how we can change a stool.
• 10:39
  Speaker 2: And we still, to this day, have patients that feel embarrassed talking about their poos.
• 10:43
  Speaker 2: But we really try and say, okay, you know, these are things that you can change, because the other option, unfortunately, is to take laxatives and between the chemotherapeutic agent that they're on what they might be on is an anti-nausea which causes often very terrible constipation and then introducing a whole variety of laxatives.
• 11:02
  Speaker 2: Sometimes now they can't leave the bathroom and so trying to show them how the different fibres make a difference.
• 11:08
  Speaker 2: So we talk about chia seeds and psyllium husks and flax meal.
• 11:13
  Speaker 2: We have what we call the old school fibre recipe here at the herbal dispensary, which is even parts of chia, quinoa and flaxseed and half a part of psyllium husk, and you either use that dry if you've got diarrhea, or soak it overnight and use it like a little pudding if you've got constipation.
• 11:31
  Speaker 2: And so we try and teach them how to bring in these.
• 11:33
  Speaker 2: Maybe add some stewed apple or grated apple, different foods, kiwi fruits, prunes, of course.
• 11:40
  Speaker 2: So really trying to show them how they can not have another drug, and not because I'm anti-laxatives at all, but because maybe it's nice to be able to get some control back and figure out foods and have an enjoyable way of getting on top of what could be potentially quite difficult bowel problems.
• 11:57
  Speaker 1: Yeah, I think any good medico would welcome any avoidance of polypharmacy if they could, as long as the patient was well looked after and was healthy.
• 12:05
  Speaker 1: So let's delve into the use of probiotics or bacteria foods.
• 12:15
  Speaker 1: Can we go through the different um cancers where different bacteria was associated with each?
• 12:22
  Speaker 2: I was looking at a couple and I'm amazed at the stuff that you've pulled up yes, look, I I have started to make a um chart and it's just at the start point because I was like we need to collate this research.
• 12:35
  Speaker 2: Surely it's been done, but I haven't seen it yet.
• 12:38
  Speaker 2: I have seen some really amazing papers that show, you know, across gastrointestinal cancers these are the kind of issues we're looking for or across female reproductive cancers, these are the species that we're looking for.
• 12:49
  Speaker 2: But I am in the process of putting together my chart that I've called microbiome and cancer to really try and pinpoint.
• 12:54
  Speaker 2: Okay, if I see a patient who has ovarian cancer, what do I need to look for or get my colleague to look for in their stool test?
• 13:01
  Speaker 2: So, certainly, um, there are consistencies and we have to remember those viruses as well, like epsom bar virus and, uh, the herpes virus, hepatitis is, you know, they're all there in those characters that could be, you know, increasing the risk of certain cancer types.
• 13:16
  Speaker 2: But from a um, you know microbiome more you know bacterial species.
• 13:22
  Speaker 2: Definitely we're seeing lots of fusobacterium, um, some Ecoli issues, you know.
• 13:27
  Speaker 2: You know mycoplasma issues.
• 13:28
  Speaker 2: It's really dependent on all the different cancers seem to have all different research coming up.
• 13:33
  Speaker 2: But I guess what I'm loving seeing uh, and of course I'm referencing my chart because I want to be as science-based as possible is that there is good consistency across all the different research and it's not like one paper is showing this and one paper is showing that it's really quite succinct in what they're seeing at this stage.
• 13:51
  Speaker 2: So I definitely think there is place for looking at microbiome for each patient, given their diagnosis and trying to figure out is this something that we should be addressing to try and rebalance or rectify what could be a disrupted microbiome, especially in places like bladder cancer and esophageal cancer, where sometimes the treatment is quite nasty and can't be sustained for a long period of time, and so any additional support we can offer those patients, you know, is really welcome.
• 14:27
  Speaker 1: Can I ask Carla, with regards to this goes for all bacteria, not just commensals or probiotics.
• 14:36
  Speaker 1: When we're looking at a snapshot in a patient who has cancer let's say breast cancer, because it was really interesting what came up about there when you're looking at a snapshot, are we seeing cause or effect?
• 14:52
  Speaker 1: Are we seeing this cause?
• 14:57
  Speaker 1: You've obviously asked yourself this question question.
• 14:59
  Speaker 1: So did it cause the problem or is it there because of the problem, trying to heal the problem?
• 15:04
  Speaker 1: What's your answer?
• 15:06
  Speaker 2: like you've obviously thought about, I think it's both I think it's both and I think some of the research has gone as far as kind of pulling that out, like the bowel cancer.
• 15:16
  Speaker 2: There's a really great paper called gut and the microbiome um, and it was one of the first ones I saw and it definitely pulls that apart a little bit and goes okay, in the pre-cancerous stages we're seeing this kind of shift in the microbiome and once a tumor develops we're seeing this kind of shift in a microenvironment and I totally I mean I'm a big advocate for understanding the terrain of tumor growth, like the tumor microenvironment, and so I think the ultimate answer is we don't know.
• 15:44
  Speaker 2: But if we're seeing bacteria or other species, yeast, parasite, things that shouldn't be there, I think it's worthwhile focusing on making a change because I think overall it has a positive effect on the tumor microenvironment and the person and that even the oral microbiome and its connection to what's happening in breast cancer tumors is just like mind-blowing.
• 16:08
  Speaker 2: So I think if we can start to make those connections, I have so many people come into my clinic, particularly in the breast cancer space, and say you know, I was really looking after my health and they're like quite devastated that they've put all this effort in yet they have been diagnosed with the cancer and I think these are the kind of, you know, oral microbiome, the kind of things these people aren't knowing about or aren't thinking about that if they've had an issue with, you know, hygiene, gingivitis, gum disease.
• 16:39
  Speaker 2: You know, maybe this is a little piece of the puzzle that we're uncovering.
• 16:44
  Speaker 1: Okay.
• 16:44
  Speaker 1: So a patient comes to you.
• 16:45
  Speaker 1: They might have gingivitis long standing.
• 16:48
  Speaker 1: You might think, oh, there's something there.
• 16:49
  Speaker 1: What do you then do about that?
• 16:51
  Speaker 1: Obviously, it's not to treat or manage the breast cancer at all, but what you're doing is basically dampening another bird, another driver of inflammation in their body.
• 17:03
  Speaker 1: So how do you treat that then?
• 17:07
  Speaker 2: Yeah, I think there's lots of amazing information coming out about the oral microbiome and I certainly want to do this more work in this space in the coming years myself.
• 17:16
  Speaker 2: But I think knowing the right probiotics to take and I think there is enough evidence to suggest some probiotic species can really be put into that dental probiotic range.
• 17:27
  Speaker 2: But I also think it comes back to hygiene.
• 17:29
  Speaker 2: You know I often ask my oncology patients have you been to the dentist?
• 17:33
  Speaker 2: And you know, I think it's one of those things that sometimes get left by the wayside and you just realise you haven't been for a while and suddenly it's been five years or, you know, three years and people are perhaps not looking after their health as much as they should have from their oral microbiome perspective and not knowing they can do something about it.
• 17:51
  Speaker 2: So there's a good microbiome testing for the mouth now so we can start to use that.
• 17:57
  Speaker 2: I haven't used that in my practice yet, but definitely if there's a link between a chronic disease whether it be a patient with cancer or some other autoimmune disease or something, I definitely think it's important for practitioners to ask that question what is your oral health?
• 18:11
  Speaker 2: Because I just don't think we have been doing that enough and it's and it is a burden that we can definitely see in the research for breast cancer and some other cancers is affecting I'm not going to say the outcome of the cancer, but it's having an impact as a driver to disrupt the microbiome.
• 18:28
  Speaker 2: That then might be having an impact on the tumour microenvironment.
• 18:32
  Speaker 1: Yeah, I also thought that you know, if somebody's got longstanding gingivitis, it's worthwhile addressing, if for no other reason than to prepare their oral mucosa for a possible assault due to the medicine, so that they're a step ahead rather than catching up behind the eight ball with regards to presenting with mucositis or a more severe mucositis than what somebody ordinarily would have, because once you can't eat, it's a really hard thing to come back from, you know.
• 19:05
  Speaker 1: So I take your point, you know, of how important that is to really get right.
• 19:11
  Speaker 1: Yeah, because if you can't eat you're on a downward sort of you're pushing a stone uphill.
• 19:20
  Speaker 2: And I think in the microbiome research has come out.
• 19:24
  Speaker 2: What really kind of shocked me when I first became aware of all this bulk of research was just no one is discussing this in australia I can't speak for other places but no one's asking their patients about um, you know what is happening to their um, their oral health around that cancer space, or what has been their experience of other, maybe microbiome-disrupting conditions.
• 19:51
  Speaker 2: Because when a patient comes with cancer, you know there's so much to do.
• 19:56
  Speaker 2: You know you're trying to keep them well during treatment.
• 19:59
  Speaker 2: You're trying to think about how the research might suggest we can stop progression.
• 20:03
  Speaker 2: You're trying to think about their emotional health.
• 20:04
  Speaker 2: There's dietary changes to be made, and I think the weight of the research in microbiome and cancer is really making me think okay, this needs to be one of the first conversations we have, not the last conversation we have, which it certainly wasn't a priority for me until I started to read all this research.
• 20:25
  Speaker 1: You also made a really good point before about anxiety and stress and things like that, about how that can have such an acute effect on the microbiota and therefore again lead them down a rocky road if they don't really watch themselves.
• 20:38
  Speaker 1: So it just paints to me how critical it is to get, as you said, a rainbow of foods and get them eating all of the really weird fruits and stuff like that.
• 20:48
  Speaker 1: So take us through a patient picture here.
• 20:51
  Speaker 1: How do patients present to you?
• 20:53
  Speaker 1: Do they present late when they're already really sick, or do they present early to say, listen, I've been given this diagnosis and I want to make sure I'm in tip-top condition for what's ahead of me.
• 21:05
  Speaker 2: Yeah, I get four different types of patients.
• 21:07
  Speaker 2: The first one is the most common and that's really when they come in that early stage, you know, they're in that stage where they're just like their head's spinning.
• 21:16
  Speaker 2: They've just been diagnosed and they may be questioning whether or not they align with the suggested treatment they've been given, and about 80% of my patients will follow the recommended treatment.
• 21:28
  Speaker 2: 10% will have run out of recommended treatment or any treatment, and then about 10% will decline their treatment.
• 21:36
  Speaker 2: And so in all of those different types of people there's a real sense of panic of what can I do?
• 21:41
  Speaker 2: So I'll get that group in, and really at that stage it's about trying to get their ducks in a row and remind them that they've got a lot of control, that their choices are theirs, that they can, um, you know, be involved in their healing and feel confident in their plan that they've chosen, um.
• 21:58
  Speaker 2: The next person is the person that's finished their treatment, and usually they have a whole lot of side effects, and so, you know, maybe they've finished their chemotherapy and they're about to start radiotherapy, or they've finished chemotherapy and radiotherapy and they've got radiation dermatitis and mucositis and diarrhoea and they're fatigued and they hate everyone in their family, but they're really scared of dying.
• 22:19
  Speaker 2: You know there's all the emotions.
• 22:20
  Speaker 2: And then it's really trying to get those side effects under control first and help them get back to feeling well after their treatment's finished, because often in that situation there seems to be just a well done, you've done, you don't need to come back for treatment, you're, you're on active surveillance or monitoring, um, and they might have three months before they get to be seen again, and that really can feel quite disconcerting to someone who's been having regular treatment.
• 22:42
  Speaker 2: So we try and build some well-being in for them.
• 22:45
  Speaker 2: The third person type I see are people who are at the end stages with really not a lot of hope and are really looking for anything they can do.
• 22:55
  Speaker 2: And I really enjoy working with those patients because it's a real pleasure and privilege to support people in those really challenging times when sometimes they might be working with palliative care teams or looking at a totally different way of dealing with their current state of health, and so that's an interesting place to work.
• 23:16
  Speaker 2: And then the other patient that I see is ones who family members have had a particular diagnosis and they're at a high risk of having that diagnosis.
• 23:25
  Speaker 1: And.
• 23:25
  Speaker 2: I think microbiome is really interesting to consider in those people because it gives us, you know, another tool that we can start to help people, along with a healthy diet and all the modifiable lifestyle factors like good sleep.
• 23:38
  Speaker 2: And, you know, microbiome gives us another way we can help support those patients to maybe reduce the risk, as the research suggests we might, if we avoid particular microbiome shifts that might be undesirable in the cancer type they're at risk of.
• 23:54
  Speaker 1: This is such an interesting thing.
• 23:56
  Speaker 1: Can I ask, when you're dealing with those patients who either decline therapy or probably more to do with palliation, do you have to spend a lot of time with realistic expectations of therapy and just say you know like, are you expecting to be cured of cancer, or are we really on the same page with what we're trying to achieve here?
• 24:27
  Speaker 2: Yes.
• 24:28
  Speaker 2: So when someone is in the initial stages and they haven't had any treatment, I actually spend a lot of time debunking myths about conventional care, because there is this bit of idea that all chemotherapy is the same and everyone is going to be bold and skinny.
• 24:46
  Speaker 2: And I ask people what do they think of or who do they think of when they think of chemotherapy?
• 24:52
  Speaker 2: And everyone has a story and it's either a loved one where it was really awful, someone else's loved one where they heard it was really awful, or things they've seen in the movies and the media.
• 25:04
  Speaker 2: And you would know, chemotherapy means a million different things, and so sometimes it's me trying to help them understand maybe because we have more time that there is um things that they need to find out before they just throw the baby out with the bath water.
• 25:21
  Speaker 2: And if my patient makes a decision that the treatment they're being offered is not right for them and it's a good, solid decision I get them to do things like use some of the tools that talk about, you know, improve life expectancy with different treatments, and they decide not to do that, I'll still support them, but I'm thinking about their whole health and I definitely have some pretty strong conversations about.
• 25:46
  Speaker 2: I'm not saying I will save you or do my damned hardest to try, but I'm not offering an alternative to standard therapeutics.
• 25:56
  Speaker 2: I'm offering another way to think about your body and the terrain of cancer and how, with or without treatment, whatever their, their choice is, we can address some of the research-based actions that might improve their whole health to be less inhabitable to cancer.
• 26:15
  Speaker 2: I was going to say the palliative care side is a whole other interesting idea where we really do get to spend time with people talking about how to make them live as well as they can for however long that may be, and that's a really interesting part of naturopathy that I think hasn't been explored as much as it should be.
• 26:41
  Speaker 2: I think there's a lot of scope for people to work in this area, but one of the most common symptoms that happens when people start to really decline is that they have a lot of trouble with digesting their food and you know their bowel function really declines and reflux and heartburn become an issue and persistent vomiting.
• 26:58
  Speaker 2: And we have lots of tools that can help, whether it be our knowledge about how to prepare the food to make it more tolerable or whether it be teaching the loved ones, how to make nutritional smoothies, or whether it be talking about digestive enzymes.
• 27:13
  Speaker 2: I think there's a lot we can offer to make people feel well in a period where they're definitely going to decline.
• 27:20
  Speaker 2: It's just how well can they be when they decline?
• 27:24
  Speaker 1: Yeah, totally agree.
• 27:26
  Speaker 1: And you know there's another point there as well, and that is we think about the microbiota and we think about affecting it like this you know bacteria microbiota or food microbiota, but you know what about sleep?
• 27:38
  Speaker 1: What about laughter?
• 27:39
  Speaker 1: What about exercise?
• 27:40
  Speaker 1: What about loneliness?
• 27:42
  Speaker 1: You know what about isolation?
• 27:44
  Speaker 1: You know what about isolation?
• 27:49
  Speaker 1: So is there something in this psychosocial sphere, or physical psychosocial sphere, that we can do to affect the microbes so that they, you know, they can then do their job at least from a healthier perspective?
• 28:00
  Speaker 2: oh for sure I love that, and even the other day what you said before reminded me about you.
• 28:06
  Speaker 2: You know I have a patient who has quite a devastating diagnosis as a young person and, despite her ultimate goal being to live a long and healthy life, her mood is really low and it's most likely the treatment she's on.
• 28:23
  Speaker 2: She's on a newer immunotherapy that is known to have negative effects on the mood, but because of the complications of the therapies, I can't use a lot of the typical mood herbs and nutrients we think of.
• 28:36
  Speaker 2: So I settled on a probiotic.
• 28:39
  Speaker 2: We know them as psychobiotics because it's coming around the back and having an impact on her mood, but not touching the area.
• 28:47
  Speaker 2: That I have to be careful because of the way that the immunotherapy works, and so I think you know it's not even about the gut.
• 28:54
  Speaker 2: I mean, it's about the gut, but it's not about the gut.
• 28:56
  Speaker 2: I'm looking to try and improve symptoms with the probiotics as well in some cases.
• 29:03
  Speaker 1: There was another interesting concept, if you like.
• 29:08
  Speaker 1: I read years ago the paper I'll always remember the author, sivan, and it was a mouse study.
• 29:12
  Speaker 1: But it was a very elegant study, it was beautifully I'm pretty sure it was Nature Journal, but I can't remember which and what they did was a crossover, so a double-blind crossover, with a washout in mice, uh, and these mice were given a pd1, pdl1 and they basically showed that bifidobacterium breve and longum helped to reduce the toxicity.
• 29:38
  Speaker 1: And I think it was that paper.
• 29:41
  Speaker 1: Forgive me if I'm wrong.
• 29:42
  Speaker 1: I'm pretty sure it was that paper where they said there appeared to be an improved efficacy.
• 29:49
  Speaker 1: That's from a probiotic, you know these are serious drugs that really affect your gut, like you wouldn't believe.
• 29:55
  Speaker 2: Yeah, and I think we're seeing more and more of that that if the microbiome isn't right in inverted commas, you're not getting the same results from treatment, and you know.
• 30:08
  Speaker 2: That just blows my mind that, okay, maybe in the future, part of our role will be in ensuring that the microbiome is, uh, in its best form to help these treatments work, and it certainly um puts weight to the fact that, okay, at the start of everything, we need to think about how we can get this microbiome to be as healthy as possible, to get the most benefit out of treatment as possible, and there there is some good studies on that.
• 30:31
  Speaker 2: Now you know, if you take x drug with or without probiotics, you know who gets the best outcome.
• 30:35
  Speaker 2: Um, and it's looking pretty positive for probiotics, yeah this is really good.
• 30:42
  Speaker 1: I look forward to that one.
• 30:43
  Speaker 1: Can I ask, before we get to the end of the show, can we make sure that we include those in the show notes for everyone?
• 30:55
  Speaker 2: If you've got them, yes, I'll find them.
• 30:56
  Speaker 2: You know, just searching microbiome and like paclitaxel was the drug I'm thinking of.
• 30:58
  Speaker 2: But there is a few of those papers around that are really, you know, worthwhile looking at when you're thinking about your patients and how we can help them with their standard care.
• 31:06
  Speaker 1: Well done.
• 31:06
  Speaker 1: This isn't probiotic driven but thinking about health, intestinal mucosa, so mucositis.
• 31:15
  Speaker 1: There's the coffee and honey, swish and spit.
• 31:17
  Speaker 1: Yes, can I ask you how late along the road?
• 31:27
  Speaker 1: How severe a mucositis have you been able to rescue with that therapy, or indeed other therapies, like you know, oral glutamine, swishing that around things like that?
• 31:33
  Speaker 1: What have you used what?
• 31:35
  Speaker 1: What works for you?
• 31:36
  Speaker 2: yeah, I really like oral glutamine.
• 31:39
  Speaker 2: I find that that works quite well and I usually get them to put it in their water bottle and just keep going all day with it.
• 31:44
  Speaker 2: So low dose over the whole day and I like that hope study, the coffee and the honey I just say to people I have handouts for all the different side effects.
• 31:54
  Speaker 2: So I say to people look, there's a study on instant coffee and honey.
• 31:56
  Speaker 2: I'm not sure where that came from, but I'll get them to use that.
• 32:00
  Speaker 2: I make oral mouth rinses with things like chamomile and calendula and, if it's appropriate, um, we do manuka lozenges, um, so lots of options.
• 32:09
  Speaker 2: I almost find what is?
• 32:11
  Speaker 2: You get great results.
• 32:12
  Speaker 2: I'd say any stage you get improvement.
• 32:15
  Speaker 2: But what I love most is when that extends to the esophagus.
• 32:18
  Speaker 2: So I think lung cancers and esophageal cancers, and there's some great papers that suggest if you use liquid, use glutamine during radiation for lung or esophageal cancer, normally 60 percent of people will end up being tube fed.
• 32:34
  Speaker 2: But when you use glutamine it really drops it down.
• 32:36
  Speaker 2: I can't remember the exact number so I'm going to be making it up, but you know, somewhere between around 10 percent of people are more likely to or are going to need it and the other 50 percent don't.
• 32:47
  Speaker 2: And so you know.
• 32:47
  Speaker 2: I think there's a lot to be said for side effects support and simple strategies like adding some glutamine to water, the coffee and instant coffee and honey.
• 32:59
  Speaker 1: I'm pretty sure it was an Iranian group who were looking at that.
• 33:02
  Speaker 1: Okay, makes sense, it's picked up in my mind, but I thought it was very interesting that it wasn't an organically grown gourmet coffee, it was an instant coffee and it was a cheap supermarket honey.
• 33:15
  Speaker 1: Now, I'm all for Manuka or Leptospermum Australian honey, I don't care, I'm all for it.
• 33:22
  Speaker 1: Higher the UMF or NGOs are trying to pull at it, but the higher the UMF the better.
• 33:29
  Speaker 1: But this was using just ordinary, everyday honey and ordinary everyday coffee.
• 33:35
  Speaker 2: Yeah, and there's another really great study for side effects from capsidabine which is called PPE.
• 33:43
  Speaker 2: It's a hand and foot condition.
• 33:45
  Speaker 2: And there's another similar paper that if you put henna on your hands and feet, which is a super messy henna, is that hair dye.
• 33:54
  Speaker 2: It must have come from a similar group because really low cost, unusual intervention.
• 33:59
  Speaker 2: It's not my first choice, but henna was researched and sometimes it makes you wonder how did they come up with these trials and get the funding for it, whatever.
• 34:09
  Speaker 2: But yeah, um henna was another thing that was suggested, and a funny one at that wow, unreal.
• 34:19
  Speaker 1: Um, okay, so what about?
• 34:21
  Speaker 1: We've covered picking up the pieces.
• 34:23
  Speaker 1: We've covered longevity.
• 34:24
  Speaker 1: We've covered picking up the pieces.
• 34:26
  Speaker 1: We've covered longevity.
• 34:28
  Speaker 1: We've covered different treatment phases.
• 34:31
  Speaker 1: We've covered a few of the red flags.
• 34:34
  Speaker 1: Is there any other red flags that you see?
• 34:36
  Speaker 1: We've covered portal of entry with PICC lines.
• 34:40
  Speaker 1: Oh, you know where you've got a wound, an anastomosis.
• 34:45
  Speaker 1: Another portal of entry it is.
• 34:46
  Speaker 1: But you know when they've had gut surgery and there's an anastomosis or something like that.
• 34:55
  Speaker 2: I'm saying to be careful with all hygiene too, because I think you know, especially in radiation dermatitis, we do a lot of topical treatment.
• 35:03
  Speaker 2: One of the things I suggest to practitioners is talk to patients about the hygiene.
• 35:09
  Speaker 2: You know, if you have radiation dermatitis and you're putting anything like, let's just say they're putting manuka honey on it, we've got to understand it'd be like hospital grade, you know antiseptic uh, or hygiene practices when we're doing anything in those patients, because they just are so susceptible to everything.
• 35:26
  Speaker 2: So, you know, a candida or thrush is another really common one, and so, you know, just making sure that we are really careful in the way that we're talking about hygiene and not getting any wounds infected wherever they might be, but also, you know, just watching the spaces that could be at risk of infection to help our patients pick that up sooner rather than later where it can be even more of a problem.
• 35:52
  Speaker 1: Can I ask, carla, do you ever combine herbs with probiotics to get an effect Like, for instance, we know in, say, urinary tract infections?
• 36:01
  Speaker 1: Combining pomegranate or cranberry helps the probiotic to make an anti-infective agent.
• 36:07
  Speaker 1: Do you ever combine certain foods?
• 36:09
  Speaker 2: Ginger is coming to light with me, but yeah, look, I would more think about the prebiotics, and probably things like ginger would feature in some of my prescriptions.
• 36:20
  Speaker 2: When we've got that probiotic, particularly if we're thinking about the kind of oral microbiome, right through the gut microbiome, I can't think of another place where I would use it.
• 36:30
  Speaker 2: But certainly most of my prescriptions would have a combination of herbs, nutrients and probiotics in it.
• 36:36
  Speaker 2: But I'm not necessarily thinking about them in a synergistic way, except perhaps if I'm using antimicrobials.
• 36:43
  Speaker 2: Of course I'm going to be careful about when I'm using probiotics and, yeah, more kind of picking up that prebiotic and probiotic actions.
• 36:52
  Speaker 1: Well, that's actually an interesting aspect about avoiding certain things when you're dosing with probiotics.
• 36:58
  Speaker 1: So let's say insulin resistance.
• 37:00
  Speaker 1: I've covered this in another podcast.
• 37:02
  Speaker 1: How heavy would you go with berberine when you're on a probiotic?
• 37:07
  Speaker 2: Yes, not too heavy.
• 37:09
  Speaker 2: I try and space them out and of course it can become really tricky.
• 37:13
  Speaker 2: I love berberine in oncology but if you've got a combination of some active treatment phase, then you're trying to get berberine in and then you're trying to get a probiotic.
• 37:21
  Speaker 2: I try not to make it too complicated for my patient.
• 37:24
  Speaker 2: I feel like quite often the more medication supplement they have to have throughout the day, the more they feel like the sick patient or the sick person, and so I would sometimes pulse it on different days.
• 37:36
  Speaker 2: So I might do, you know, every second day is berberine and the alternate day is probiotics.
• 37:41
  Speaker 2: I've even lately, with a few patients started to say have the weekend off, because I do think sometimes when we've got all of these supplements that they're taking particularly if people have got lots of side effects to address, it can just they get supplement fatigue, and so I do think something is better than nothing.
• 37:59
  Speaker 2: So when people are feeling like there's a risk of things not being great together or they're feeling overwhelmed, you know, having a day or two off especially if it's a scheduled day or two it's like your relaxed day can be really a nice way for patients to feel more normal than perhaps taking something every day or having lines of pills they've got to get in between their meals, and you know whatnot.
• 38:25
  Speaker 1: Carla, where can we find out more information?
• 38:27
  Speaker 1: Obviously, there's a heap of papers and we're going to put up as much as we can on the website for in the, in the show notes.
• 38:33
  Speaker 1: But what else are you doing around this area?
• 38:37
  Speaker 2: Yes, I've done a presentation for Designs for Health, so you can check out that recording on cancer and the microbiome.
• 38:44
  Speaker 2: I've also got lots of trainings for practitioners and a podcast on talking about oncology support for patients, and so I do that under the brand Prosper, so you can check that out on my website, listen to my podcast and learn more about just how amazing the amount of complementary medicine research there is and how we can really work to support patients to have as healthy a life as possible while having a cancer diagnosis.
• 39:16
  Speaker 1: So the podcast and the website is Prosper.
• 39:19
  Speaker 2: Yes, so you can go to my website CarlaWrencom to find it there, or ProsperCancerCareco to find it there or prospercancercareco.
• 39:28
  Speaker 1: Beautiful Carla Wren.
• 39:29
  Speaker 1: Thank you so much.
• 39:30
  Speaker 1: This is only an inkling of what you can, obviously, what your knowledge base is, but thank you so much for taking us through just a chipping away at the iceberg so that practitioners, and therefore their patients, can get the best out of their health and their wellness while they're along their cancer journey.
• 39:47
  Speaker 1: Thanks so much for joining us today on Wellness by Designs.
• 39:50
  Speaker 2: Thank you for having me.
• 39:51
  Speaker 1: And thank you everyone for joining us.
• 39:53
  Speaker 1: Remember Carla's webinar is going to be up on the designsforhealthcomau website.
• 39:58
  Speaker 1: Log in, look at the Education tab and you can catch up on all of the other podcasts on the Designs for Health website.
• 40:05
  Speaker 1: I'm Andrew Whitfield-Cook.
• 40:07
  Speaker 1: This is Wellness by Designs.