[00:00:00] Dr. Katie Deming MD: When you hear the words cancer treatment, do you only think of chemotherapy? ~ ~Today I sit down with Dr. Jason Konner, a medical oncologist at the renowned Memorial Sloan Kettering Cancer Center.

[00:00:11] Dr. Katie Deming MD: Dr. Konner specializes in gynecologic cancers and has spent the last two decades witnessing how cancer treatment has rapidly evolved. You'll learn the key differences between traditional chemotherapy, targeted therapies and immunotherapies, and why it's important to know which one is right for you.

[00:00:29] Dr. Katie Deming MD: We'll also talk about how doctors decide on a first line treatment, what to ask when a new drug is recommended, why getting a second opinion is not only okay, but often encouraged stay until the end to hear

[00:00:41] Dr. Katie Deming MD: the surprising factor that could make immunotherapy less effective, something most ~patient~ patients never think to bring up.

[00:00:49] Dr. Katie Deming MD: Let's dive in.

[00:00:58] Hello everyone. [00:01:00] I'm Dr. Katie Deming, and this is The Born to Heal podcast where we explore holistic practices for cancer prevention and healing. Let's welcome today Dr. Jason Konner, medical oncologist and full professor at Memorial Sloan Kettering Cancer Center. Welcome, Dr. Konner.

[00:01:17] Dr. Jason Konner: Nice to be here, Katie.

[00:01:19] ~ ~

[00:01:19] Dr. Katie Deming MD: So Dr. Konner, I am so excited to have you on the show and what I wanted to bring you on to talk about is. The different types of therapies that are available for people who are healing cancer.

[00:01:32] Dr. Katie Deming MD: From a conventional standpoint, and I know specifically you're a medical, you are a medical oncologist, but a lot of people actually may not even know what a medical oncologist is. So I'm wondering if you can describe kind of generally what are the different types of treatments, and then what does a medical oncologist do?

[00:01:49] Dr. Katie Deming MD: What are the treatments that fall under that? And then we'll go deeper into figuring, you know, explaining what those. Types of treatments are and, and when people would seek them.

[00:01:58] Dr. Jason Konner: Sure, [00:02:00] absolutely. Well, the very basic categories, there's surgical oncologists who do surgery and radiation oncologists, as you mentioned, do radiation. And those are mostly for local treatments, uh, of cancers in variety parts of the body. And then you have medical oncologists who do, who do everything else.

[00:02:17] Dr. Jason Konner: Uh, and, and much of what we do from a therapeutic standpoint, uh, is give what we call, uh, systemic treatments for cancer. And by systemic we mean treatments that go everywhere in the body. And so, uh, very simply, you can break that down into traditional chemotherapy, uh, targeted therapies and immune therapies.

[00:02:41] Dr. Jason Konner: I would say are the big three categories there. And you know, the traditional chemotherapies are mostly developed in the 20th century, uh, but are still very present for many cancers. Uh, and those are basically treatments that are usually intravenous but can also be pills and that go in the body and basically kill [00:03:00] dividing cells.

[00:03:01] Dr. Jason Konner: That's what they do. And they can do that through a variety of different mechanisms. So there's dozens of different. Cytotoxic chemotherapies out there, and they all have their own side effects, uh, and specific cancers where they, they work better or or worse. And, you know, much of what we do is figuring out which are the best, uh, chemos for this particular disease entity and for this particular patient, and help prepare them for, you know, what are the challenges of those treatments and systemic,~ um, uh,~ targeted therapies. You know, really are, are mostly from this century, starting kind of in the late nineties, but very much in the last 20 years. And those don't necessarily just go in and go into the nucleus and just break up dividing cells by attacking the DNA, which is mostly what the cytotoxic chemotherapy do. What targeted therapies do is they go after, uh, some of the biologic mechanisms of cancer growth.

[00:03:57] Dr. Jason Konner: And try to inhibit them. So, uh, a [00:04:00] common example is, uh, cellular signaling. ~Uh, so, uh, ~cells decide to divide or not divide based on chemical signals that are taking place in the cytoplasm. And some of those, um, signals are amplified or inhibited in specific cancers. And those can be, um, targeted by targeted therapies.

[00:04:21] Dr. Jason Konner: So very often, uh, you might see a cellular signal that's just turned on and it because of a mutation. This, you know, the protein is saying grow, grow, grow, keep growing. And by identifying that in a specific patient, uh, sometimes we have, um, usually a pill that can block that mechanism, and, and ask the cell not to divide.

[00:04:43] Dr. Jason Konner: and then finally the third category I mentioned were immune therapies. And that's a. Umbrella term for any sort of treatment that basically, uh, in some way stimulates a patient's own immune system to help fight their own cancer. And there's a variety of ways of doing that these [00:05:00] days. and that's really just the last 15 to 20 years that we've seen that come into the fore.

[00:05:04] Dr. Jason Konner: Uh, but it's really had a transformational effect on the way we treat many cancers these days.

[00:05:09] Dr. Katie Deming MD: ~Yeah. ~Well, and I'm wondering. You know, you brought up a word cytotoxic, and I think that this, just so that people know what cytotoxic means is basically it's killing the cell so it's toxic to the cytoplasm or to the cells. And so, you know, when people think of chemotherapy or. You know, systemic therapy often they just bucket this all together and they think everything is cytotoxic chemotherapy, which as you describe it's not.

[00:05:37] Dr. Katie Deming MD: And, and more and more today we're using these other therapies like targeted agents or immunotherapy that really have a different approach. Their approach is not to kill the cell, but to. Either boost the immune system with immunotherapy or to block a specific mechanism. Mechanism within cell signaling.

[00:05:57] Dr. Katie Deming MD: I'm wondering if you can describe, because [00:06:00] when people, you know, hear cytotoxic chemotherapy, they think, oh my gosh, no, I don't want that. Because they're thinking of all of the traditional side effects of hair loss, nausea, vomiting, weight loss, feeling super fatigued. I'm wondering if you can describe.

[00:06:18] Dr. Katie Deming MD: What is the difference when someone has, let's say, immunotherapy? Like what is the side of, and I know it's so complicated, these are like such general questions and, and just so people understand is Dr. Konner is a medical oncologist who specializes in gynecologic cancers. So this is very, very nuanced from like, it's.

[00:06:40] Dr. Katie Deming MD: There's so many different drugs and it depends on the type of cancer, right? And so, you know, your scope of practice is like really narrow because it is so nuanced with this. There's so many different places that people can go. So I just want people to know that we understand this as a very complex topic, and we're taking broad strokes here just to [00:07:00] help people understand so that when they go into meet with a medical oncologist, they feel more informed about what these.

[00:07:07] Dr. Katie Deming MD: Different types of therapies are, so yeah. What are like some of the differences in terms of the side effect profiles that you could think of? Of targeted agents or immunotherapy versus conventional therapy?

[00:07:17] Dr. Jason Konner: Yeah. Well, it's a great question and, and I could talk for, for days about this literally, but, um, but the details really matter. Because there are so many different types of treatments and so many different types of cancers and so many different types of patients' bodies and the way that they, um, react with these medicines and these diseases.

[00:07:38] Dr. Jason Konner: Uh, and it's, uh, there are such individual differences. But very often when a patient is newly diagnosed and they're not very familiar with cancer and its treatments, they may say, well, I knew this person. Uh, and that person was very thin and bald and sick, and I don't wanna have that experience for me. or they may know someone who said, oh, they just took a pill and everything [00:08:00] went away and they were fine.

[00:08:01] Dr. Jason Konner: And I hope that can happen for me. And so, uh, and those things, and those do exist, uh, but everybody's different and, and extrapolating somebody else's story often is not going to be, uh, the correct thing to do for an individual. So really educating oneself on exactly. Uh, you know, what their diagnosis is.

[00:08:22] Dr. Jason Konner: Uh, and, and that can differ not just by body, uh, location, but also specific cell types and even specific molecular differences among these cell types can determine. Which chemotherapy or targeted or immunotherapy is right for them. And very often there are combinations of these types of therapies today.

[00:08:42] Dr. Jason Konner: So it can get, the waters can get very muddy. But I would say in general, when we talk about, you know, the term I mentioned, cytotoxic, chemotherapy, those traditional chemotherapies that we, we think about that kill dividing cells, um, there's a lot of commonalities to the types of side [00:09:00] effects we see.

[00:09:01] Dr. Jason Konner: Nausea, fatigue, uh, sometimes hair loss, sometimes nerve injury. Uh, sometimes affecting the circulating blood cells in our body, like the, the red cells where you can get anemia or the white cells. You can lower your immune system, uh, to varying degrees, uh, and the platelets. So those are just a, a few of the common things that we see, but there are some chemotherapies that will cause your hair to fall out and some that won't, and some that will cause nausea and some that don't do that so much.

[00:09:34] Dr. Jason Konner: So the, the individual type of chemotherapy really matters. And, and sometimes there are, uh, combinations of several chemotherapies at once and it can get a little confusing. Um, but it's really important to spend time, ~um. ~Uh, the treatment team and, and educating oneself about what are the possible side effects about the specific treatment that's gonna be involved here.

[00:09:59] Dr. Jason Konner: ~Um,~ [00:10:00] when we're talking about targeted therapies, uh, those are often in pills, but sometimes they are intravenous antibodies. Uh, and antibodies are these y shaped proteins that go in the body and bind to one specific thing, uh, whatever we decided in the lab that it should be binding to. ~Um, and so, uh,~ these pills or these antibodies will go after one specific, uh, target, uh, part of the mechanism of the cancer.

[00:10:26] Dr. Jason Konner: Those treatments can sometimes have very few. Side effects, but sometimes can have really difficult side effects. And sometimes these pills can be harder on the body than the traditional chemotherapies. Uh, and I, there's a tendency to think, oh, it's a, it's a pill. It's targeted, it's going to be easy. Uh, but that's not always the case.

[00:10:47] Dr. Jason Konner: ~Uh, and, um,~ even when there are side effects that aren't necessarily dangerous, some of them, you know, you can get severe acne or you can get diarrhea. Um, or you can get just, just fatigue and a little bit of a [00:11:00] tummy ache and these kind of cr chronic symptoms can really wear on somebody. So a pill isn't always easier.

[00:11:08] Dr. Jason Konner: And these antibodies are, are all over the place. There are so many different types, the field of antibody targeted antibodies, even though all of them are these yha proteins and they all sound similar, the target that they target, uh, has a big influence on exactly what kind of side effects they're gonna be.

[00:11:24] Dr. Jason Konner: Antibodies are generally going to be intravenous, but these days, sometimes they're subcutaneous. As the technology is advancing. Um. And, uh, a lot of the new immunotherapies are also antibodies. When we talk about immune therapies, we're really talking about harnessing the immune system, uh, which is pretty amazing.

[00:11:45] Dr. Jason Konner: Our body, uh, in so many cases, is able to fight the cancer with its own, um, its own inner technologies, its own wisdom. It just needs to be given that permission. However, the risk of these immune therapies is sometimes when we unleash the immune [00:12:00] system. Uh, it can go after some of our normal healthy cells, and so some of the immune therapies carry the risk of causing inflammation in our normal organs that can mimic autoimmune phenomena. Yeah.

[00:12:14] Dr. Katie Deming MD: Well, you know, you brought up an a really interesting point when you were talking about the tailor or the targeted therapies and that, how some people think, well, I would just want that because it's just a pill, and that's gonna be easier than the, um, traditional, um, chemotherapy. And one of the things that's interesting that I see sometimes 'cause people come to me for like, you know. Not a second opinion about their conventional therapy, but they're wanting kind of another person to look at the broad picture and help them make decisions, right? And then put a holistic plan in place to help them, you know, with symptoms and get to the root cause and that kind of thing. Um, more of a holistic approach, but.

[00:12:56] Dr. Katie Deming MD: I will often run into people where they're like, I [00:13:00] don't wanna have, and I'll just give this example, this was a woman who had breast cancer and she's like, I don't want chemotherapy with Taxol, because Taxol is a drug that is like, you know, so old and it's, you know, it's archaic and all of this stuff because it was an old drug.

[00:13:17] Dr. Katie Deming MD: And so she wanted some new targeted agent and I don't even remember what it was at the moment, but. a person who's practiced in conventional medicine for two decades before I left the system, I'm thinking, you know what? I kind of want the drug that I know what the side effects and I know the history and I know the data that we have decades of data around this, how it works.

[00:13:40] Dr. Katie Deming MD: Then something that what the other agent that she wanted was not even something that was approved. It was a trial, and I was like. First line therapies, and maybe we can talk about that actually. Like how is it decided, you know, first line, second line, third line, so people can understand that if con, if you're gonna go a conventional route [00:14:00] and you know, cytotoxic chemotherapy is recommended at as first line, you know there's a reason for that.

[00:14:08] Dr. Katie Deming MD: And so can you speak to that? Like you, you know what I'm talking about. I'm, I'm sure my audience doesn't know fully what I'm talking about yet, but I would love to have this conversation.

[00:14:16] Dr. Jason Konner: yeah. Uh, you raised some very, very, uh, relevant, uh, and important points here. Um, chemotherapy, even though some of it is many decades old, remains the cornerstone of treatment, systemic treatment for so many different types of cancers. Uh, and here and there we're seeing instances of where new, um, less toxic treatments are replacing.

[00:14:43] Dr. Jason Konner: Chemotherapy. Um, but for most of the common cancers, chemotherapy remains a cornerstone of treatment. Uh, and it's excellent. And I would say about chemotherapy. It's, it's fairly predictable. individuals will have different [00:15:00] sensitivities to different toxicities. That's a hundred percent true, but we know roughly what's going to happen.

[00:15:05] Dr. Jason Konner: Uh, and we have a lot of data about the, uh, effectiveness of it. and also we have the advantage. These are, for the most part, very inexpensive drugs. Uh, we don't have, uh, industry pushing, uh, to get Taxol. Taxol is used because it's a great drug. Whereas some of the new drugs that are coming out may have some marginal benefits that in, in these very large studies show, you know, incremental PFS advantage, uh, whereas most patients may not be really benefiting, uh, to the same degree that they're benefiting from chemotherapy.

[00:15:40] Dr. Jason Konner: So certainly that history, uh, of, of use is really important.

[00:15:45] Dr. Katie Deming MD: And can you describe like, you know. Because I'm in this now alternative space, but I, I, I bridge really like, you know, people who are gonna do conventional, like as it's written and then people who are [00:16:00] like, oh, I'm not doing any of that, and they wanna do a water fast, or whatever. And then I have people in the middle.

[00:16:04] Dr. Katie Deming MD: And actually the biggest dangers that I see. Are sometimes in the middle because people want to Frankenstein and put together and they're like, well, I don't want that drug because of this. Whatever. They have some experience or they've read something and then they put, I want this, and they wanna put stuff together.

[00:16:22] Dr. Katie Deming MD: But there's a. A way that you decide on what is the first treatment for someone versus, okay, if it comes back, then, you know, we've tried this and this hasn't worked, then we're gonna do this. Can you describe how are those decisions made? Like how is it decided? What treatment is gonna go first? And would you ever recommend people like.

[00:16:45] Dr. Katie Deming MD: You know, convincing their doctors to combine drugs in like different ways that the, the studies don't, necessarily, um, support.

[00:16:53] Dr. Jason Konner: I would say that. For different cancers at different stages of the disease [00:17:00] process, there are different levels of how compelling the data are to support specific regimens. Uh, very often the first line systemic regimen, you know, the first thing you receive after surgery or before surgery, uh, there's going to be the most data for, uh, and that's, that's what's going to, you know, usually whatever the standard of care is.

[00:17:21] Dr. Jason Konner: He's going to be pretty well established. Uh, and also importantly, very often the first line, uh, treatment, uh, may be an opportunity for cure, whereas, uh, if for a recurrent cancer may or may not be an opportunity to cure. So if you have a potentially curative therapy, uh, that's something that you may not want to forego.

[00:17:46] Dr. Jason Konner: ~Um.~ If there's, uh, a reasonable chance that it's going to do that for you. Uh, whereas in the later lines of treatment, when somebody's getting third or fourth line and maybe there's not really an established standard of care, there's a little bit more [00:18:00] flexibility. You know, ultimately a patient has the, the, you know, absolute sovereignty to make the decision for what's best for them, for their body.

[00:18:09] Dr. Jason Konner: But I would absolutely advise to, um, take that recommendation for first line treatment very seriously when, when, you know, the stakes are very high and the data often are very strong for the benefits. ~So, um, and~ and in terms of how to integrate, uh, some more holistic therapies. Um, that's something that's ideally done in collaboration with, um, the conventional doctor and the, and the integrative doctor.

[00:18:38] Dr. Jason Konner: And unfortunately there's not a lot of direct communication, uh, that goes on for perhaps ideological reasons and for perhaps practical reasons, uh, that there's a variety of barriers to that. So, um, I would encourage patients to maintain open communication, uh, in both directions. Uh. [00:19:00] Um, and not to have to apologize for anything and just be very plain, this is what my preferences are and this is what I'd like to do, and I'd like to do this safely.

[00:19:08] Dr. Jason Konner: And I appreciate your support and, uh, hopefully most, most, uh, physicians will be, um, uh, attentive to that and caring to that because most patients really are looking for something more. Outside of what we can offer. You know, we very often are offering really difficult therapies and sometimes with limited, um, promises of what they can do.

[00:19:32] Dr. Jason Konner: So it's completely understandable to look outside these walls. Uh, and I think the more that we talk openly about this, um, the, the better. Um, but also for patients to really be educated and think about this. I mean, so often there are. Trends on, on, on the internet are, are, there are unscrupulous, uh, salespeople out there trying to take advantage of patients who are in a desperate [00:20:00] situation and making a lot of false claims.

[00:20:02] Dr. Jason Konner: Uh, and I think, um, you know, it's very important to use discernment about what is really sensible for, for you and your journey, uh, and what, you know, maybe not such a good idea. And, ~and, ~So it requires really just paying attention, asking a lot of questions, doing research, but doing good research, you know?

[00:20:21] Dr. Katie Deming MD: Yeah. Well, and I think that. I love that you said that about the communication and, and that's, there's an episode, uh, for my listeners. You know, I've recorded another episode with Dr. Konner with one of his patients who's also one of my clients who did a water fast and. He, you know, you speaking to listeners about you, but basically you have been such an ally and open, um, physician to the other, you know, things that Donna, my client and your patient has [00:21:00] wanted to do.

[00:21:00] Dr. Katie Deming MD: And so I've always said that we'll always do better if we're all working together and we can communicate. But I think one of the thing that's. It's, that's difficult for many patients is that their doctors are not as open as you are. You know, you've been very. You're always clear, like my primary goal is to keep my patients safe.

[00:21:21] Dr. Katie Deming MD: And so you're always looking out for Donna, like, you know, make sure whatever you're doing that is safe, and then if you're, if we're doing anything at the same time that she was having some systemic therapy with you, that nothing would interfere, you know, and making sure, so I a hundred percent agree with that, with the communication.

[00:21:38] Dr. Katie Deming MD: What do you say to someone who's seeing a doctor and they are really interested in doing holistic practices and they're just like, their doctor is saying, 'cause I heard this just the other day, like, you can't do any of those things if you're gonna have treatment here. Like you can't do any supplements, you have to stop all of that.

[00:21:56] Dr. Katie Deming MD: You can't do anything. What do you, what do you say to that?[00:22:00]

[00:22:00] Dr. Jason Konner: Well, I think that the relationship between a patient with cancer and their medical oncologist is a really important one. It's a really, uh, sacred relationship. And I, I think that's at the core of, of the patient's journey and, and, you know, in with conventional medicine. Uh, so I think it's just stepping back from that question, um, am I being listened to?

[00:22:25] Dr. Jason Konner: Uh, and can I express my needs and, and, and, and issues, you know, in a safe and supportive environment. Uh, and so I, I think it's just really important to make sure that you feel, you know, that an individual feels comfortable, uh, in that relationship. and so if their team is being completely dismissive and doesn't want to discuss, then there's a lot of, uh, ego in the room and like.

[00:22:52] Dr. Jason Konner: Oh, I know more than you're Google and you know, things that, that come out. Um, then I would be wary of that, not just for [00:23:00] that question, but just, uh, is this doctor's ego coming in the way of my needs in general? Uh, because I think that's a big issue in the field. I think that, you know, when ego enters. The relationship, it's bad for the patients and it's bad for the doctors too.

[00:23:17] Dr. Jason Konner: And that's something as a field that we need to work on some more. Uh, and sometimes it's ego and sometimes it's just, it's really difficult to do anything more than we're doing in a day because doctors are really, uh, stressed and strapped for time and they just don't have the bandwidth. To do more than what they're doing or, um, don't wanna put in that extra time.

[00:23:39] Dr. Jason Konner: And that's understandable that a lot of doctors are burned out. And then sometimes there are very good reasons. Uh, for instance, if a patient's on a clinical trial. A lot of clinical trials can afford, you know, great things to patients these days. So there's a lot of exciting, uh, beneficial new medicines on trials that are coming out.

[00:23:58] Dr. Jason Konner: And very often there are very [00:24:00] strict rules that are really there for safety because if a, a drug is new, we often don't know what the interactions are going to be and what the pharmacokinetics are. You know, how it interacts with the body and is expelled from the body. We don't really know the details of that.

[00:24:13] Dr. Jason Konner: So in the setting with trial, it's really important to be super careful with supplements and, and other treatments. So I think understanding, uh, why, uh, the doctor is, is responding this way is the, is the first part of this. Is this someone I can communicate with and do I feel safe in this relationship?

[00:24:30] Dr. Jason Konner: And listen to, I think those are the, the first questions.

[00:24:33] Dr. Katie Deming MD: No, I think that that's super helpful and I love that you brought up that other point of why, you know, what, is it just that they're completely closed off and not open to hearing what's important to you, or is there really a valid reason why in this particular setting it's not, you know, they don't want you doing anything extra because it actually is required by the clinical trial to, you know, have, be.

[00:24:58] Dr. Katie Deming MD: Explicit about what [00:25:00] exactly people are taking. So I think that that's important. And I think, you know, this is the one thing that I always say to people is they're like, the doctors, you know, it doesn't feel like a good fe fit. They're not listening to me. I don't, and then they're, but they're afraid. And I always say.

[00:25:15] Dr. Katie Deming MD: It's okay. They're so busy. It's okay if you go get a second opinion or if you switch to a different doctor. This happens all the time. Like in our clinic we had, you know, people would end up switching oncologists and no one thinks twice about it. Because if you think about it, we're human beings and we're developing a relationship and we're not gonna be a match for everyone.

[00:25:38] Dr. Katie Deming MD: And so that's one of the things that I would like to. At least allay people's fears that if you do find that this isn't the right fit for you, it's okay to switch. It's okay to look for another doctor or even in the same clinic.

[00:25:51] Dr. Jason Konner: Yeah. Yeah. I think that the, that relationship is so core to the healing process, and it's not really supported by the [00:26:00] system, you know? Writing chemo and, and doing and looking at labs and sort of the basic, um, you know, more substantive, recordable things, uh, are, are what are, uh, demanded of us and asked of us.

[00:26:14] Dr. Jason Konner: Uh, but ultimately what is so important is that, is that relationship and that listening and that conversation, uh, and that sometimes gets lost in the, the shuffle of the process.

[00:26:25] Dr. Katie Deming MD: Yeah, for sure. Well, and I don't expect. Any conventional doctors to be abreast of this other stuff, because that's not the job. Like you said, that's not their job description. They have all these things that they are responsible for. But I think the big thing is, if this is important for you, is just to have someone who's open and then I would find, you know, a holistic practitioner who can then communicate in, in, in.

[00:26:49] Dr. Katie Deming MD: Help your doctors, you know, say, okay, this is, these are the things that we're doing. You know, is this okay? And like when I was practicing radiation oncology, if someone was going to see a naturopath, I'd be [00:27:00] like, you know, just let them know this is what you're having, what you're having done. Send them a list of what they want you to be taking, and then everything's great.

[00:27:07] Dr. Katie Deming MD: Then everyone knows and we're all working together and keeping you safe.

[00:27:10] Dr. Jason Konner: Absolutely. I think that the field is stacked against this type of relationship. I. Conventional medicine, uh, doctors come out of, uh, you know, come into the field without having this openness, um, in, in their hearts because that's not the way that they're trained and that's not the way the zeitgeist of the field often is.

[00:27:31] Dr. Jason Konner: So, I think so often these things are missed.

[00:27:34] Dr. Katie Deming MD: Yeah. Let me ask you this, like, so with, targeted therapies or immunotherapies.

[00:27:41] Dr. Jason Konner: Mm-hmm.

[00:27:42] Dr. Katie Deming MD: Are there some things that you would have people knowing that it's nuanced, knowing that it depends on, you know, what signal abnormalities that they have in their cells and you know, genetic profiles of their cancer. Are there general things that you might advise people to be [00:28:00] aware of or before going into these therapies?

[00:28:02] Dr. Katie Deming MD: And I know that's a broad question, but maybe even if you just had examples of, you know, specific targeted therapies or immunotherapies, just so that I think one of the things that. I always want to do is help people to know what are the right questions to ask, like what are the questions that I should be asking when I'm, you know, offered different therapies.

[00:28:21] Dr. Jason Konner: ~um. ~Yeah, the, uh, one thing is that these treatments, as we were saying before, they're just not right for everybody. And it really depends on, uh, on the cancer and some of the molecular details and on the individual. So you want to think about all these issues in terms of molecular details.

[00:28:39] Dr. Jason Konner: Sometimes there are different proteins expressed on the cancer that there's, we do special, what are called stains to look for different proteins that will tell us whether or not. This drug or that drug might be best for an individual patient. And sometimes we do comprehensive testing of the DNA of an [00:29:00] individual's cancer, and that sometimes, uh, reveals incredibly valuable information about what exactly is the best treatment for this patient.

[00:29:11] Dr. Jason Konner: Uh, sometimes it's not helpful at all, depends on the cancer. Um, and sometimes those tests can be done with blood tests. Sometimes they're, they're done with the tumor that was taken and the biopsy, or from the surgery. Um, but that's a question that should be, you know, on almost everybody's minds, uh, what is my cancer?

[00:29:33] Dr. Jason Konner: What is the subtype of my cancer? What are the molecular tests that have been done or need to be done? To help make sure that I'm finding the right treatment for, for me. Um, because using, um, targeted therapies if you don't have the right target sometimes can cause a lot of harm. Uh, and similarly with immunotherapies, uh, some of these molecular indicators can have a very strong impact.[00:30:00]

[00:30:00] Dr. Jason Konner: On whether or not the patient might benefit, uh, from this treatment. In addition, there are patient factors that need to be looked at. So for example, as we mentioned before, we're sort of recruiting the immune system into action with a lot of these immune therapies. Uh, and if autoimmune phenomena are potential, uh, consequences, we have to ask, has the patient a history of any autoimmune disease?

[00:30:30] Dr. Jason Konner: And that might, might that come back. Uh, you know, something comes in and they look fine, but they just had rheumatoid arthritis that has been sort of quiet for the last year. Um, if they receive an immune therapy, they might be at risk of reactivating that. ~So, um, ~you know, asking about, about those things and just being aware of those things in one's history are, are really, really critical.

[00:30:52] Dr. Jason Konner: ~Yeah.~

[00:30:52] Dr. Katie Deming MD: Well, and I'd love the questions of, okay, what is my type of tumor? What is the subtype? What is the testing [00:31:00] that either has been done or needs to be done to make a. The right decision for therapies with this, once they've been presented with therapies, what are the things that you know? People should be asking, obviously, you know, when I'm talking to people, I'm always saying, you want to understand what are the benefits of that therapy, right?

[00:31:21] Dr. Katie Deming MD: And then what are the short term side effects or risks while you're having the therapy? You know? And those are things that won't last forever, but they can be, you know, significant in terms of quality of life. And then what are the potential long-term complications? Is it for you the same thing? Are those the things that you would tell people that if they were presented with a therapy, those are what they should be asking about?

[00:31:41] Dr. Jason Konner: Those are all really important questions. Um, I think I would, I would add to that what are the, uh, foods or medicines that I, uh, need to, or don't need to avoid while I'm doing this, or what are the activities that I need to, or don't need to avoid while I'm doing this? Because, uh, some [00:32:00] patients have the presumption that on treatment they need to live in a bubble, uh, or they can't have sushi or, or drink alcohol or, or you know, they start, Depriving themselves of seeing, uh, a family member like a baby. They don't know how to do a baby because they're scared they're going to, uh, you know, affect the baby with these toxins that are coming out of them. And if it's really important to ask these questions, uh, because not knowing these answers can really affect somebody's life, if they suddenly were like, I need to take all these precautions that you don't necessarily need to take.

[00:32:32] Dr. Jason Konner: So, uh, I think those are really, uh, sometimes overlooked questions. Are that are not asked, um, you know, that I would, that I would bring into the conversation. ~Um,~ with immunotherapy, there are increasing, uh, data coming out about various things that can potentially decrease the effectiveness of immunotherapy.

[00:32:55] Dr. Jason Konner: For instance, overuse of antibiotics. And that, that may not be obvious, [00:33:00] but that's something to look into. Even use of probiotics, certain types of probiotics can, uh, decrease the effectiveness of immunotherapy. So really fleshing out those sorts of questions, um, I think can be really valuable for, for patients.

[00:33:17] Dr. Jason Konner: You know, what do I do when I'm not here?

[00:33:19] Dr. Katie Deming MD: Yeah. Well, no, I think that that's actually really, I. Important that, that I, I didn't think about that. Like, you know, the foods to avoid or, you know, have while you're having chemotherapy or the activities, because I'm assuming that their doctors are gonna tell them all of that. But you're right that people sometimes make assumptions and it's something that their doctor hasn't asked.

[00:33:42] Dr. Katie Deming MD: So asking those questions is, is really important. And, um, you know, the. It's interesting, I hadn't heard that about decreasing the efficacy with antibiotics or probiotics. So this is one question is that, you know, when [00:34:00] people, they go in and they see the oncologist and then they come out with some crazy new drug that's like, I can't even spell it, let alone pronounce it.

[00:34:08] Dr. Katie Deming MD: You know, and it's like all these things and, and they're just like, I don't know, it's, you know, some. They don't know whether it's targeted or immunotherapy. If someone goes, and this is just a question for you in general, so for people when they go to Google, you know, 'cause they are gonna look up these drugs or you know, also they should have a printout from their doctor.

[00:34:28] Dr. Katie Deming MD: Would it say specifically in there that this is a immunotherapy drug, you know, or No? Right.

[00:34:34] Dr. Jason Konner: Not

[00:34:34] Dr. Katie Deming MD: how do they even know that it's an immunotherapy drug?

[00:34:37] Dr. Jason Konner: I mean that's, that's a framework that I often use to discuss with patients, but they're not clear categories at times. And, and as the technology is advancing, uh, there are some drugs that don't fit neatly into these categories. And there's a huge new field of what are called ADCs, which stands for antibody drug [00:35:00] conjugates, where you have these yha proteins, the antibodies that bind to target and they carry with them a chemo.

[00:35:06] Dr. Jason Konner: So I think of it as targeted chemo. It's both targeted and it's chemo. And then we have some, uh, other antibodies, these y shaped things. Normally they bind the same thing on both tips, but now we have some that bind one target with one tip and another target with the other tip. One of them might be an immunotherapy target, and the other might be a targeted therapy target.

[00:35:30] Dr. Jason Konner: So there's a lot of overlap with some of these emerging treatments that are becoming really common. you know, I think that that's a nice just framework, overall framework for patients to think about, to get comfortable with this. But as you dig deeper into this, it can become a little more complex.

[00:35:45] Dr. Katie Deming MD: ~Yeah, and I think,~ I think. It is becoming so much more complex for, I mean, for you, I mean, I know just in oncology, I think you and I actually started practicing around the same time. My first, um, position outset outta residency was 2006. I think you were [00:36:00] similar around then. Yeah. Okay. So, I mean, both of us have been practicing for two decades.

[00:36:06] Dr. Katie Deming MD: I remember when I first started practicing, there were, you know, the chemotherapy regimens. It was very specific, and we had hormonal therapy, but none of this stuff existed. And then I remember as probably like now, maybe 10 years ago, that it just started exploding. And the amount of information, even for the doctors, this is one of the reasons why.

[00:36:28] Dr. Katie Deming MD: You know, as a medical oncologist who does these systemic therapies, you often end up specializing in a specific type of cancer because it's so complex. Even within that, to keep track of all of these therapies and all of these targets and all of this new emerging, um, you know, pharmaceuticals are becoming available for the patients.

[00:36:52] Dr. Katie Deming MD: It's almost like mind boggling. They can't even, you know, because. When you can at least put 'em in categories where you're like, okay, this is a conventional [00:37:00] chemotherapy, this is a targeted therapy, this is immunotherapy. They can somewhat wrap their head around it, but now it's so challenging because you're right, like it's so complicated.

[00:37:10] Dr. Katie Deming MD: And then maybe they're mixed. I didn't even know this was a thing, the, the mixing of the two. Um,

[00:37:14] Dr. Jason Konner: Yeah,

[00:37:16] Dr. Katie Deming MD: and so I, I

[00:37:19] Dr. Jason Konner: it.

[00:37:20] Dr. Katie Deming MD: You know, the question I guess is this, is that, well, or I guess the challenge that I am seeing, 'cause I see people on the other side of it where they get these inserts and they're just like, their eyes are just, you know, like spinning.

[00:37:32] Dr. Katie Deming MD: 'cause they just can't keep track of any of this. They're really reliant on their doctors, giving them accurate information. More so even than in the past where you had just these, you know, specific regimens. It was like breast cancer. It was like, you know, we're doing a CT or whatever it was. And it was, you know, a lot of people getting that same thing.

[00:37:53] Dr. Katie Deming MD: Now everyone's getting something different because as you described, everyone's different. Everyone's got, you know, [00:38:00] different, um, features to their own cancer. But then it becomes even scarier, I think, for people with some of these therapies because you don't have as much information and there's so many different ones of them.

[00:38:12] Dr. Jason Konner: ~Yeah, yeah, ~yeah. I mean, this is a, a huge point. I mean, the more we, uh, learn, uh, and the more this field is differentiated, the harder it is for individuals to keep up with all this and we could be become increasingly specialized. And, um, I think people don't realize also that rare cancers are really common.

[00:38:31] Dr. Jason Konner: So, and it, you know, there are 400 different types of cancer at least. And so if you added up all those rare cancers, those are, uh, as are more common than the common cancers combined. Uh, so it's, it's really common to have a rare cancer and sometimes it can be very hard to get good information. And it's been impressive how there are some patient, uh, led grassroots movements.

[00:38:56] Dr. Jason Konner: Uh, of just coming together often on these, uh, Facebook [00:39:00] groups to really just share information about these rare cancers, especially with patients who aren't close to, uh, an urban center, whether you might find the right specialist. Uh, and so that can be a really valuable resource. I mean, sometimes you, you might not find great information, but sometimes patients can find really a amazing information on some of these, on some of these groups.

[00:39:21] Dr. Jason Konner: But yes, I mean, it gets so complex and you. Even cancers come from our own bodies, so they are at the core as individualized as we are. Uh, and they evolve over time and sometimes even in different parts of our body, we're treating different, different entities. Uh, and so the oncologist, you know, as an oncologist, I form a relationship with my patient's specific disease.

[00:39:47] Dr. Jason Konner: This particular cancer, you know, likes to grow quickly and then respond well to chemo or this particular cancer, the tumor marker is very sensitive, and you start to learn these things. About individual cancers, [00:40:00] uh, some of which really have no precedent. And I so often get the question from patients, have you seen this before?

[00:40:07] Dr. Jason Konner: Uh, and the answer is always yes and always no, because I've never seen exactly this no matter what it is. And no matter how much I do this, I have never seen exactly this. Everybody's story is different, but I've seen enough that I can get a sense of what. You know what I might do here. So it really, you know, can get very, very nuanced.

[00:40:27] Dr. Jason Konner: Um, and yes, the more we know and the more we learn, we're, we're, we're keeping patients alive for longer now, and it's really amazing. Uh, but things get even more complex as you get to fifth line therapy in six line therapy with different diseases and there's more and more drugs coming out. So the, the, the struggle is real, uh, for sure.

[00:40:48] Dr. Jason Konner: And, um. You know, being a generalist I think is just really, really hard. So it can be valuable for patients to sometimes get a second opinion, even for, you know, one, [00:41:00] uh, critical decision making time in their disease with a specialist if they're not sure if their doctor is familiar very often. I'll see the, you know, I'll see patients whose doctors are very welcoming for a second opinion.

[00:41:14] Dr. Jason Konner: I think so often patients are scared of offending their doctor by se seeking a second opinion. And I think it's really important to know that it can be really refreshing and really great. And a generalist is like, do it great. I'm so excited. I wanna know, I wanna see if we can share knowledge. So I would encourage patients to really be open, you know, be open to that.

[00:41:33] Dr. Jason Konner: 'cause very often doctors are open. And if they're not, that comes back to some of the ego and dismissive issues that we were discussing before. Uh, but I think in, in general, that's, that's a really, uh, that could be a really valuable thing for patients.

[00:41:45] Dr. Katie Deming MD: Yeah. Well, and I always say, look, when when I was practicing, I'm like getting a second opinion is great because either you're gonna go and you're gonna see them and they're gonna confirm that the plan that we've developed is what they would recommend, and then [00:42:00] you're gonna feel good about that. Or if they come up with something different.

[00:42:03] Dr. Katie Deming MD: Then that's good too, because maybe they're looking at it from a different perspective. And I'm always open to that. And I think actually that is a sign of a doctor that you want someone who is open to you going for a second opinion. Because the truth is, is that I. If you, if there's the option for a second opinion, it means the first one is also an opinion, right?

[00:42:25] Dr. Katie Deming MD: It's not like gospel that when a doctor sees you, and this is it, this is the only thing because you could see multiple doctors and maybe get multiple different answers, which I don't think is necessarily a bad thing. It's, it's good actually to have the more minds you have thinking about something. I think it can get problematic.

[00:42:42] Dr. Katie Deming MD: People can go for like, you know, too many opinions and then they get very confused. I think having a second opinion and being able to either confirm what that first opinion recommended or to be able to look at from a different perspective. And then, and then you're just getting, you know, good information. [00:43:00] And I also, I loved what you said about the Facebook groups and I think that this is really valuable for, especially some of these, like I'm thinking about. Um, there's one that I saw for, uh, Heba Cellular Carcinoma, or it was a neuroendocrine tumors of the liver. Like they get very specific, but what's beautiful is if you can find one of these where it's well run and they're bringing in good people who have, you know, real knowledge in this area.

[00:43:29] Dr. Katie Deming MD: And usually it is the rare ones. It's the ones that you don't have. And then they've got a champion kind of doctor who's very knowledgeable in this region who will come in maybe and talk. Those groups can be very helpful to gathering information.

[00:43:41] Dr. Jason Konner: Absolutely.

[00:43:42] Dr. Katie Deming MD: And there are some Facebook groups that can be really problematic where you're just seeing people are just spewing stuff that is like not at all science, you know, there's just like, they're just giving their opinion.

[00:43:53] Dr. Katie Deming MD: And so you had to be discerning. And I think that for anyone listening, those Facebook groups can be great [00:44:00] and. You wanna be really cautious when you go in and you wanna look at the things, what is allowed to be post. If people are just posting their own experience of just one person having a specific experience, that's not gonna be super helpful.

[00:44:12] Dr. Katie Deming MD: Because like you said, I mean you've, you've said this and you've seen thousands of patients. It's like, yes, I've seen this before and no, I haven't seen this before. So one person who's experienced this type of cancer certainly doesn't have. Their perspective, the broad perspective or knowledge to really, you know, understand the full depth of, uh, complexity here.

[00:44:32] Dr. Katie Deming MD: But I think that the, the groups can be helpful just in terms of gathering information.

[00:44:37] Dr. Jason Konner: Absolutely. Absolutely. And also, uh, finding specialists who can give a good second opinion. That's a good place to exchange that sort of information. And, and yes, I mean the, the art of medicine is still very much alive. I. Even, even with all our technology, it's still a critical component of this. And partly because, you know, this, the gold standard of, of data that we use, the [00:45:00] randomized phase three prospective clinical trial, uh, those, um, take a long time and are really expensive and don't happen very often.

[00:45:08] Dr. Jason Konner: And in the meantime, we have a lot of new information coming out. And how does this apply to the individual? Or if you have an individual who wouldn't have qualified for this? Very specifically defined randomized phase three clinical trial. How do we extrapolate those data to this patient? So judgment, um, and, and, and the art are still very, very relevant for individual patient decisions.

[00:45:30] Dr. Jason Konner: So a second opinion can be really valuable to put more heads together on that.

[00:45:34] Dr. Katie Deming MD: Absolutely. Well, Dr. Konner, it's been a pleasure again to chat with you. I'm wondering if you can tell people where could they find you if they're interested in learning more about you?

[00:45:44] Dr. Jason Konner: I don't have much of a social media presence. Um, you know, I have, I'm on this Sloan Kettering website. Uh, I don't know how interesting it is there, and I, I think I'm discussed in a lot of these Facebook Tech groups, though I never really visit them. Uh, but I think I can, a lot of information came about me can be [00:46:00] found there.

[00:46:00] Dr. Jason Konner: I'm told.

[00:46:00] Dr. Katie Deming MD: Yeah. Well, I'm so grateful that you're coming on here to share your wisdom with us and with my audience. So thank you so much for being here. It's always a privilege to talk to you.

[00:46:10] Dr. Jason Konner: my pleasure, Katie. Happy to be here.

[00:46:12] ​

[00:46:12] Dr. Katie Deming MD: Thank you for being here today. Please enjoy a previous episode of Born To Heal, and if you found value in our conversation, please subscribe and share with someone who might benefit. Have questions, drop them in the YouTube comments or message me on Instagram or links are in the episode description. And remember, just like me, you were born to heal.