Survivorship / Survivorsh!t: Fatigue

Leah 0:00

I T.

Tina 0:01

You got to start over.

Leah 0:04

That was such a good one, too.

Tina 0:06

Okay. Do it just like that.

Leah 0:07

Okay. Hold on. Hi Tina. No, that's too enthusiastic. That's too much. Hi Tina.

Tina 0:28

Hi, Leah. How's it. going

Leah 0:30

It's going awesome. I just tallied up the score of our, survivorship song contest.

Tina 0:38

on Instagram.

Leah 0:40

Yeah. Where I had kind of put it out there, like what song represents survivorship to you? And we got about 10 nominees and then the people spoke and we have a winning song,

Tina 0:58

Alright. I honestly don't know what it is, so give it to me.

Leah 1:02

the winning song, and it was close. It was, it was pretty close. But, the song that won was, Shake It Out by Florence The machine.

Tina 1:11

Oh, okay. Yeah.

Leah 1:12

Yeah.

Tina 1:13

I actually know that one.

Leah 1:14

Oh, cool. That's so that's so unusual.

Tina 1:18

I know.

Leah 1:19

And then, well, and then what came in second, in a very close second was, Boulevard of Broken dreams by Green Day.

Tina 1:27

which I'd probably know but

Leah 1:28

You'd know if you heard it? Yeah. You,

Tina 1:30

It's when titles, aren't the actual refrain of the song.

Leah 1:33

yeah, no, I mean, you would, you would, you would know the song.Ifyou heard it? And then number three was, I'm still standing by Elton John,

Tina 1:40

Sure, okay, that one I know.

Leah 1:41

You know that

Tina 1:42

And that one I again, the refrain of the song is the title. So that helps,

Leah 1:46

does But, um, no, there were some really good nominees and some songs that, I wasn't familiar with. I winning song going to go on our, um, Spotify playlist, but I might throw a couple up there that, I thought were really great songs that I don't think a are familiar with because I like the obscure song, so

Tina 2:05

me ask you this. You had ten songs?

Leah 2:07

Yes.

Tina 2:07

Yeah. What stops us from putting all 10 up there?

Leah 2:10

Well, it was a contest.

Tina 2:15

They can have our undying gratitude for choosing the

Leah 2:17

for

Tina 2:17

popular one.

Leah 2:17

That is true. That is true. Maybe I'll do that. We'll see. We'll play it by ear. But yeah, I could do that.

Tina 2:22

All right. We'll see.

Leah 2:24

We'll figure it out.

Tina 2:25

council We'll bring it to our board.

Leah 2:27

Well, we'll take it to the cancer pod council. It's like the vampire council we'll take it to the council and they will determine it. Okay. So Tina, we are starting a pod on survivorship. So what's interesting with some of these songs is were like Fightera Christina survivor by Destiny's child. And then there's Boulevard of broken dreams by gI mean, this really dramatic, dramatic. Like, you know, either it's survivorship positive me or like survivorship is a slog. what's the definition of survivorship,

Tina 3:03

Yeah. So, you know what interesting about the word "survivor" in general is that some people take to it and other people abhor the word... like can't stand.

Leah 3:13

Right? It can be polarizing.

Tina 3:15

Yeah, I've had a lot of patients in the past say they don't like it. They don't like to be considered a survivor. They don't like the connotation.

Leah 3:22

Is it because it's like one of those kind of battle terms like fighter and survivor?

Tina 3:28

Yeah, I think it's I guess to some people it's not enough, like "I'm more than a survivor." Um, "I want to be a thriver. I want to be healthy and well, I don't want to just survive."

Leah 3:37

Oh, okay. So that's like really kind of literal.

Tina 3:40

Yeah. Yeah. I think that's, that's from what I've gotten back. The feedback I've gotten back from patients, but I would always tell them the story of how the term even came around. survivors and survivorship is not a term we've always had actually arose in the mid 1980s. And, and who is credited with the word is a doctor, his name is Fitzhugh Mullen, M-U-L-L-L-E-N, and he wrote, he's a doctor, right. He was already a physician at the time that he himself was diagnosed with cancer. He went through some intense surgeries and intense treatments, and he then wrote about it in a paper, and the title of the paper was, I believe it was Seasons of Survival. and he went through seasons of survival. Like, he survived this intense cancer treatment. He's on the other side. He's I think he was late thirties, early forties, somewhere in that range. He wrote about the seasons of survival and he defined them as acute, extended, and permanent, which was interesting. Right? So,, active treatment was the acute season of survival. And then extended season of survival was considered the five year period after treatment. And then for those who didn't have recurrence Um, he called a permanent season of survival and they had different challenges, different, physical challenges, mental challenges. So, he's writing to his colleagues to apprise them of the experience as a patient and how he, tried to capture how the patient's needs change over time. And that you're a survivor, from the time of diagnosis onward, the entire reason for doing this was to advocate for patients to say, you know, it's not like life just resumed to normal. You are now changed in some way and so he was trying to begin that dialogue. And I think that was the beginning of really looking at this post-treatment period. Of course our treatments were getting better. So we were having higher number of people who actually went through treatment and went on to lead a long life. And so he wanted his fellow colleagues to define it differently and to acknowledge it mostly that needs vary.

Leah 5:44

And I think that's, I mean, that is such a hot issue right now It seems like there are more and more younger people who are being diagnosed and like, is this what my life is going to be like? Is this, is this how it's going to be for, you know, however many decades I have, or however many years, whatever your future holds is this what it's going to be like? You know, the, um, the side effects can, can go on and on. And what was the number that, we found how many cancer survivors there are.

Tina 6:19

so the estimates for the number of cancer survivors keeps going up and they are estimating 22 million cancer survivors in the next and that's just based on the aging population that doesn't take into account improvements in treatment. but I think it's going to be higher.

Leah 6:36

And that's in the

Tina 6:37

Yeah. That's in the

Leah 6:38

Yeah So I mean, that's a heck of a lot of people and you know, the side effects that we're going to be discussing in this pod. I mean, these are also side effects that are experienced by patients in active treatment So the number one concern of cancer survivors that I hear is fatigue and fatigue starts with treatment. I remember when. I started my treatment for breast cancer. When I started the Adriamycin Cytoxan and I had my first cycle and I was walking down the hall and I ran into my surgeon and he asked, how I was doing. And I was like, I am tired. And he's like, "Already?" And I was like, "Yes, I'm working full time and I'm going through chemotherapy. Already." But then, um, then it just kind of snowballed from there. And it's the type of fatigue is I'm sure your patients have tried to describe it to you. it is like this like fatigue that comes from like your cells. It's like every cell in your body is fatigued and it's overwhelm

Tina 7:43

ng so you're saying mental fatigue, emotional fatigue, physical fatigue,

Leah 7:47

Just like every single part of you, like, you know, if you have hair, your hair would be fatigued. And it's just, and it would just come over you like a huge tidal wave and just, you know yeah. And it did, it still does every once in a while, I'll just like, feel this like overwhelming fatigue. And I will tell my husband, like this is like chemo, fatigue. I don't know what's going on. You know? And this is like seven years out. I think I am, maybe? I should know this doing the math in my head.

Tina 8:22

seven-ish well, during treatment, I think it hits you rather suddenly, right. Especially if you're getting something like chemotherapy or certain types of treatment that lead to anemia

Leah 8:33

Right radiation big one,

Tina 8:35

yeah. You go from normal red blood cell counts to a new. In the matter of days or weeks, you're going to feel that more profoundly than if you developed anemia over the course of months or years, you know, in, for example, women with iron deficiency, anemia out there, right. That's rather common and cycling women, but they don't feel that profound fatigue like you do during chemo. Cause it's kind of like you hit a wall,

Leah 9:01

Right.

Tina 9:02

let me ask you this. You said it kind of comes and goes. Do you have normal energy on some days, most days,

Leah 9:08

Define normal.

Tina 9:12

Pretreatment Um, well, it's also different, right? I mean, I'm not doing the same things I was doing. Pre-treatment I mean, pretreatment, I was working full time and now I'm, I'm not, I mean, I'm busy most days, but it's, it's just, it's like, I have a different life that's happening right now. So it's hard to say if it's the same, type of fatigue or not. So for today's discussion, shall we stick to post treatment

Leah 9:37

Yeah, I think we should stick to post-treatment fatigue, but some of this can apply to anyone who is. Currently going through treatment, But, you know, before trying anything new, they would need to check with their doctor.

Tina 9:49

Okay.

Leah 9:49

and for people who but maybe they're on something like an aromatase inhibitor or, they are on an ongoing treatment. I mean, obviously check with your doctor to check with your doctor.

Tina 10:02

so let's talk about some, some contributing factors and causes post-treatment

Leah 10:07

Post-treatment fatigue. so the NCCN guidelines had mentioned that comorbidities. Would be a cause of fatigue. And I just want to kind of get those out of the way, because those, we can spend days talking about that.

Tina 10:24

So when you say comorbidities, what you mean is other conditions that are at the

Leah 10:29

Right. That would be unrelated. It could be related or unrelated to. so a condition like hypothyroidism, low thyroid function, especially after getting radiation to the head.

Tina 10:40

Okay. Yeah. According to the NCCN guidelines for cancer related fatigue, that includes things like pain, emotional distress. disturbance, which we've covered in depth in a part one, and part two podcasts in the past, alcohol or any substance abuse. And they also include other conditions. So, uh, concomitant that might be contributing like a heart issue, that kind of thing. they put cancer treatments to quillay, which would include some of the things I just mentioned. So some of those things, whether it's neuropathy some pain or emotional distress, because people are anxious about, recurrence, there can be a lot of sequelae from treatment that lead to, contributing factors for.

Leah 11:23

Right. And I would think. List, but I would include things like, you know, brain fog or chemo brain. I mean, that's, that's exhausting trying to, trying to manage your

Tina 11:33

Yeah.

Leah 11:34

when you're living in a land of, of brain farts. I mean, it's, it's tiring.

Tina 11:38

Yeah. So you mean the, the energy it takes to just function on a day to day

Leah 11:42

Yeah. I think for some people, for sure.

Tina 11:44

Yeah, that makes sense. Yeah. And they did mention in the NCCN guidelines, they did mention that, fatigue, seldom occurs by itself is how they put it and they, and they said it usually occurs alongside one of three things, sleep disturbance, emotional distress, which is depression or anxiety or pain of. And so I thought that was an interesting thing. And they, they were saying cumulatively, when you look at studies looking at cancer related fatigue, they say it usually goes alongside one or more of those.

Leah 12:13

Interesting. So what's going on, like in our bodies, metabolically in terms

Tina 12:18

um,

Leah 12:19

fatigue

Tina 12:19

so a large part of the fatigue, cancer related fatigue can be due to the hypothalamic, pituitary, adrenal axis dysfunction...

Leah 12:29

Oh, the HPA axis.

Tina 12:30

Yes, classic HPA axis. And if you don't know about it, if you haven't heard about it, you read about it um, the HPA axis is responsible for our circadian rhythm. It's also the system we use, or at least it gets engaged during fight or flight, and so due to a lot of things that happen during treatment, the system can be dysregulated afterwards. This includes things like steroids during treatment can throw off the HPA axis, stress, anxiety, being in that fight or flight mode chronically, maybe, or at least, you know, maybe a lot more anxiety than the body normally has that all triggers the HPA axis. And so by the time someone goes through treatment and comes out the other side, sometimes the HPA axis needs to be re-established, and we need to put together some lifestyle measures

Leah 13:20

To reset it.

Tina 13:22

Basically reset it. It's like this. Cortisol goes up when you're stressed out. Steroids like dexamethasone, predisone, those kinds of things, mimic our own cortisol. Cortisol's job when we have a burst of cortisol- like, I always use the car as an because this happens to anyone who's driving. Someone, you know, goes out in front of you and you, you get, you know, this jolt, that jolt includes not just your adrenaline jumps, which is another word for epinephrine, adrenaline. Your cortisol also goes up right then and it tells your, hypothalamic pituitary axis to produce a big burst of cortisol. But once it's high, that high a mount of cortisol goes up to your hypothalamic pituitary axis and your brain goes, "oh, there's a big burst. Let's stop making it!" It's like a knee-jerk reaction. You have a burst of cortisol and then you stop and you get over it. When you're on steroids or you're under constant stress. Imagine the cortisol is constantly high. It no longer responds. It doesn't shut off. It creates this continuous loop of high cortisol, and that's a chronic stress pattern, and what you're asking of your own adrenal glands when you're under chronic stress is to continually make cortisol. And at some point it can't do that anymore. The old term and, not a very well-liked term these days, is adrenal fatigue or adrenal exhaustion.

Leah 14:45

That's kind of considered woo woo.

Tina 14:47

It's definitely considered woo woo. It's a very colloquial term too. I mean, I think, I think it conveys the end result in that the adrenal glands are not creating enough cortisol to have a normal rhythm. So you can end up with a low cortisol state eventually. but it's not a truism. It's not like your adrenal glands are actually fatigued or exhausted in any way.

Leah 15:09

It's old school.

Tina 15:10

It's definitely old school. So back to rhythmicity, so when you're under chronic stress and your HPA axis stops hearing the high cortisol, I' m going to put that in air quotes, "hearing" that there's high cortisol and it's not able to come down, it keeps the cortisol high. High cortisol throughout the day, and throughout the night will disturb your sleep, cause anxiety. And it's linked to higher rates of recurrence. So high cortisol, consistently high cortisol, where it doesn't come down in the nighttime... after dinner time, our cortisol should continue to go down, down, down, dinnertime, nighttime, you put your head on the pillow. Your cortisol is all should be at its lowest point and it stays low throughout your sleep. And then it jumps back up in the morning. And so that's part of the 24 hour rhythm of our cortisol, right? So we have this anxiety provoked stress, provoked high cortisol state that we should come down off of, we're healthy and resilient, i f our HPA axis is resilient, then we have this 24 hour background of cortisol. So these are the two ways the HPA-axis keeps us healthy. The 24 hour rhythmicity of your cortisol can be thrown off by that high cortisol state when you're in that high stress mode for a long time, if you continue that can lead to sleep disturbance. And like I said, it is associated in studies with higher rates of recurrence. for at least breast, renal ,and ovarian cancer at the very least, there's probably others. So what we'll talk about when we go into the lifestyle factors and things that we can do to help, we'll talk about the HPA axis and how to get that normal rhythm back because foundational to health is having a normal circadian rhythm, 24 hour rhythmicity of your cortisol pattern.

Leah 16:54

so what you're saying is, obviously any co-morbidities need to be addressed. If there is depression going on, if there is chronic pain, those need to be addressed, but, the foundation would be addressing the axis? I'm assuming.

Tina 17:10

So you have the comorbidities, right? So the pain, sleep disturbance, all of these things are overlapping, right? So pain could be causing the sleep disturbance. The lack of circadian rhythm can cause sleep disturbance, anxiety can cause sleep disturbance. Like I don't think that we can necessarily pull them apart completely because there's so many overlapping features. Right. And

Leah 17:33

Right.

Tina 17:34

And the NCCN guidelines recognize the HPA axis dysfunction as a major part of cancer related fatigue.

Leah 17:40

And other things that could be going on include like inflammation, right?

Tina 17:45

yes, systemic inflammation is associated with fatigue along with a lot of the other sequelae of cancer treatment, like brain fog, uh, aches and pains, arthritis, muscle pains

Leah 18:00

RIght.

Tina 18:00

Yeah. So systemic inflammation is definitely something that should be on the table. And that can be checked pretty easily with just doing an ESR and a CRP on labs, especially the CRP, which is C reactive protein. I think it should be ordered on labs. Wellness panels for people who are getting their blood work done, post-treatment to see where that's at, because things can be done to bring it down. And generally when you lower the CRP, you feel better. I mean, whatever the inflammatory symptom you're having you know, is usually relieved with bringing down the CRP. So the other, piece of the metabolic things that are happening post-treatment and some of this is ongoing. So some people are taking a drug, whether it's Tamoxifen, aromatase inhibitor, or maybe one of these tyrosine and kinase inhibitors for treatment. another thing that happens is mitochondria of the cells can be impaired, even destroyed. So constantly we are regenerating mitochondria in our cells. energy manufacturing within the cells themselves. It is the mitochondria. nte So some drugs are directly toxic to the mitochondria, but certainly when you go through treatment, at least stressed to the point of some destruction and what regenerates our mitochondria is exercise. So we go through phases of creating more mitochondria within cells when we demand more energy from the cell. So maybe you had to rest a lot more than usual. You didn't have energy because of your anemia. So you weren't up and about as much during treat. That means the number of mitochondria per cell is going to go down because it will go up as needed. Right? So mitochondrial damage directly or indirectly is also one of the reasons that there is fatigue afterwards.

Leah 19:40

So that's a great case for, trying your darnedest to do some form of exercise during treatment.

Tina 19:46

Yeah. All the studies show that movement is your friend.

Leah 19:50

Yeah.

Tina 19:50

Yes.

Leah 19:51

And when you're yeah. When, when you have one of those waves of fatigue, come over you, sometimes that just seems hard to do. I used to write, prescriptions for my patients to dance. that every. Everyone has a song that gets them to dance. And so I would tell them, you know, put it on your phone, just have it where you can just like push a button and just move. Even if you're laying on your bed, just like put your legs up and dance on the ceiling.

Tina 20:20

Uh-huh, uh-huh.

Leah 20:21

just, just to get people moving. I guess we're kind of, we're kind of moving on to what is helpful and, we've mentioned exercise.

Tina 20:28

yeah, yeah. Exercise is interesting. because going back to that HPA axis, it can be very calming. Like you go for a walk or you, you do some gentle exercise, yoga. Um, most yoga would count, you know, walking your dog, that kind of thing. it can lower cortisol. So that's what you want to do after dinner or in the evening. And you don't want to do vigorous exercise. After a certain time in the day, like mid-afternoon after, after mid-afternoon is when you don't want to be doing vigorous exercise because vigorous exercise raises your cortisol level. And that's the time of day that you kind of want it to be down on the downward slope after, certainly after two or three o'clock in the afternoon. And by the time you go to bed, like I said, it's good and low. So you want to do calming things in the evening, more vigorous activity earlier in the day.

Leah 21:13

And so the recommendation In terms of cancer survivorship, for exercise is 150 minutes of exercise per week. And that includes aerobic exercise and resistance training. So that can seem- talk about overwhelming- mean, just doing the math. Like that seems like a lot of exercise, but it can be broken down. You can go for a five minute walk, you know, you can then do maybe 20 minutes of resistance training. So that's, let's round it. Let's say it's half an hour a day, but if you don't have the time to you know, go to a gym for half an hour, you can break it up. And so maybe going for a brisk walk earlier in the day, and then at night doing a little bit of like wind down yoga that could be a way to incorporate it into a busy schedule,

Tina 22:01

Yeah, I think that's a, that's a really good idea. Especially during treatment.

Leah 22:04

but even after treatment, when, suddenly, you know, you're back at work and then, you've got the kids and all of this, it's like, how do you squeeze that into your day? Just knowing that that half an hour, a day of exercise plus, or minus, you know, a few minutes not have to be consecutive.

Tina 22:20

Yeah. And by moderate, moderate is generally defined as not being able to have a long-winded conversation like we're having right now, but to be..

Leah 22:30

You call me longwinded?

Tina 22:32

To slightly, uh, incapable. So you're breathing too heavy to have this kind of conversation, but not so heavy that you're gasping for breath or, you know, you're pushing your heart rate too high. So just so we're clear, moderate is somewhere in between, what we're doing now and being completely. completely incapable of saying a full sentence.

Leah 22:53

so what I noticed when I was going through treatment and then, I still notice it like being on social media, after treatment is that there are people on Instagram who are posting pictures of themselves, you know, training for races. I remember there was this one woman I followed when I was in treatment, who was some sort of executive at a outdoor company here in the Portland area. And she's doing cartwheels on the beach and doing all of the stuff like while going through treatment. And I'm just laying on the couch thinking," no," and I unfollowed her because I just couldn't deal with that, with that pressure, that peer pressure to like do cartwheels on the beach when you can't even do that before cancer diagnosis. There is a lot of push for people to exercise. and in some ways like the peer pressure is good. And in other ways, it's like if it's alienating especially if someone doesn't

Tina 23:53

Yeah.

Leah 23:53

have a history of exercise before diagnosis.

Tina 23:56

Yeah. That's why I usually use the word movement because I don't think we should, you know, especially if someone hasn't been exercising suddenly say, yo, don't forget to do your, you know, your weights, you know, I think we need to be realistic and people need to check in with where they're at more and more centers are beginning to put exercise. as a department at the center, kind of like they've been doing for cardiovascular health. I think the oncology centers are coming around and saying, we need. our exercise center. And so there, there's more research going around this because there's plenty of research showing, how exercise benefits people, and movement is enough during the treatment period and afterwards, maybe working with professional for a short amount of time for your own safety. Makes sense.

Leah 24:38

You mean trainers? Yeah, And it, it would need to be somebody who is familiar with, working with cancer patients,

Tina 24:43

Yeah. Yeah.

Leah 24:45

Some of the other, kind of like non drug treatments that are considered, category one evidence, by the NCCN would be yoga, which is the movement and massage.

Tina 25:00

Yeah, that's nice. Good excuse to get a massage.

Leah 25:01

Oh my gosh. You know, do you know how many people wish that it was covered by insurance? And I don't believe it's ever covered by insurance unless it's done in a physical therapy type of situation,

Tina 25:13

Yeah,

Leah 25:13

That is so unfortunate that that massage is not covered by insurance

Tina 25:17

Yeah. And other therapies like acupuncture, of course, which we always like to mention.

Leah 25:21

I know, I know it's just like, it's just, it's a given. I think what we should do is just always assume acupuncture is going to help with something. And if it doesn't, we'll bring it up then. So yeah. Acupuncture is a given. Um, definitely it can be helpful, but again, I know, I know we're talking about after treatment, but it does help during treatment as well. So, there is a lot of that overlap. yeah, and, there's more and more evidence for yoga as being supportive for fatigue. And it doesn't have to be, you know, when working at the cancer center, we would have yoga classes and a lot of them were restorative and restorative yoga is great, but, just because you're going through cancer treatment or you went through cancer treatment doesn't mean you need to stick with restorative yoga. You can do, you know, more active yoga

Tina 26:07

Yeah.

Leah 26:08

to help with, fatigue. you probably want to end it kind of on a more mellow note,

Tina 26:13

so the other thing that at least NCCN guidelines point to is cognitive behavioral therapy, both for the fatigue as well as for sleep issues. cognitive behavioral therapy is getting more and more validation in studies for various issues that arise. So that's something. I don't know how insurance treats this stuff. I really don't. I mean, maybe some programs, if it's at the cancer center, maybe it can be included. I don't know.

Leah 26:39

Yeah, I'm not sure either, but yeah, like those are pretty much where like the guidelines stop. but there are studies showing other things can be beneficial. like diet and certain supplements.

Tina 26:53

Yeah. So one of the things to consider, especially immediately after treatment is nutritional deficiencies, weight loss, muscle deconditioning. So atrophy of the muscle, because it hasn't been used. So all of these things that can contribute to fatigue, right after. So looking at nutrition, we talked about movement, so that would help with conditioning, but nutrition and making sure that there's no nutritional deficiencies and that's everything from B vitamins to just proper caloric intake. Right. Just making sure you're eating enough to have enough energy

Leah 27:24

right? It's There was an interesting post that I saw on Instagram. Krystal Zuniga, who is she's a oncology dietician. She has her doctorate in nutrition and she had a post that went over a study where over a two-year period, they looked at patients stage one to stage three colorectal cancer, and they increased their fiber, fruit and vegetable intake and showed improvements in fatigue over two years, you know, just kind of like self-evaluating. So if anyone is interested in that they can check out Dr. Zuniga's Instagram, which is cancer nutritionHQ. She's got a lot of good info.

Tina 28:06

That's great. I think the biggest thing is to eat real food.

Leah 28:09

And when you're tired, it's not always easy, but there are, I mean, there are workarounds.

Tina 28:15

Yeah. I think some of the pre-prepared meals that are being delivered, some of them are getting rather healthy. So, I know in some areas there is actually services that will deliver free meals that are very healthy. They bay area has some of that going on in the Eugene area. Eugene, Oregon, um, I think they've evolved to beyond cancer treatment. Basically it's chefs that volunteer and they get together with high school kids, usually who are volunteers, then some people who will deliver and they have gleaners out there, gleaning out of the fields of whatever is in season. it's kind of an amazing

Leah 28:49

There's one in the Phoenix area, the Joy Bus Diner,

Tina 28:54

Okay.

Leah 28:55

and they actually had a physical diner too. And so you could go there and, we'd go there. Sometimes it was right near our house. And so we'd go and have breakfast there, but they also had a service and that, but that was for people who are in active treatment. in terms of like those. You know, the food prep boxes we did, HungryRoot for awhile and that's all plant-based. Well, I think now they've changed it. It's now they've expanded to beyond, vegan, but, those were really simple and it seemed to have, I mean, it's a lot of packaging waste, but it's, it's an option. And I think of things like, those prepared salad bags and, Trader Joe's is always my go-to for something that it's like, you can kind of buy it. It's like almost prepped and then you doctor it up and throw in more veggies or something. So there are, there are workarounds for, if you're just a little too tired to, cook all the time.

Tina 29:45

Yeah. Yeah. And one thing people can do is get a, like a Vitamixer or something similar that like a high powered blender NutriBullet, and do something most days of the week, in my favorite thing to advocate for is, um, greens and a fruit. I don't care about the green or the fruit, whatever you like to put together, whether it's, kale and apples

Leah 30:05

spinach is pretty benign. Like, I mean, spinach of all of the greens, kale can really, you know, you need something

Tina 30:11

sweet

Leah 30:12

and maybe a little, like a little bit of lemon or something to kind of mellow that out. But spinach is easy to disguise if you're trying to disguise it from yourself and then throw in some chocolate and you're good. No, I used to make a, a smoothie at work and it was mango spinach, coconut water, cinnamon, and some ground flax. then I think vanilla protein powder. And I called it the Apple Jack, cause it kind of tastes like apple jacks, which isn't a bad taste.

Tina 30:41

Hmm.

Leah 30:42

I mean, you know,

Tina 30:43

No.

Leah 30:43

like six year old kid

Tina 30:46

but yeah, you can doctor it up as much as you want. You put a little apple cider or some coconut water or whatever you have handy. You don't want to be too high in sugar. Um, but generally the more bitter, the green, the sweeter, or the fruit you need to oppose it.

Leah 30:59

And that's why I added the ground, flax like, you know, how fiber slows down, sugar absorption. So

Tina 31:07

Yeah. That's why I advocate for Nutrabullets, Vitamix, those things that keep the whole plant together. Right. So that you're getting the fiber, not just the juice, because that just extracts all that fiber and you end up putting in compost or your garbage and you

Leah 31:19

You can cook it back, you know, put it in into, to foods. But yeah. our dieticians always recommended if someone was going to juice to not have the juice as the meal, but to choose with a meal because otherwise it's sugar and then you have a sugar crash and then you're tired again. and real quick, just one thing about sugar, sugar is one of those things where it can create like a vicious cycle. So like caffeine, right? I mean, you have You're treat like 3:00 PM. You know, you're getting filled on a little run down, you might have a little coffee drink, um, maybe some, some sweets and pastry or whatever, and then you crash again. And so, just trying to avoid that sort of, that cycle of refined carbs and caffeine, which may just perpetuate the fatigue. So focusing more on, on the nutrients in food. To help to provide the energy.

Tina 32:11

Yes. and the idea of getting these micronutrients, this is a lot easier than figuring out what to cook all the time. That's why it's kind of a little bit of coverage, little safety net of nutrients that you would be getting in.

Leah 32:23

Oh, to do you know, doing the, the smoothies.

Tina 32:27

Yeah. Maybe you're too tired to cook every meal with a bunch of vegetables and, you know, cut and chop and cook and do all of that. But if you can do a. Blended Vitamix or whatever, most days of the week, then you would have this kind of safety net of plants going in your body, which I think is the most important part is

Leah 32:44

those too, Like, h. don't have a Vitamix, surprisingly. I know, right. I don't even have a ninja. no it's because I want one that has a glass. thingy, a glass. My blender has a glass. What does that thing called? Piture?

Tina 33:01

got

Leah 33:02

wonder if one bed, I don't think they exist, but anyways, we digress. you can make soups in those things from. You can heat them up.

Tina 33:11

Yeah, you can, you can. Yes. You can make a nice, nice cream soup and those two. Yes, it's true. Or a cream, less cream, you know?

Leah 33:17

Oh yeah. A little bit of coconut milk. I should keep posting recipes.

Tina 33:21

We're also heading towards our lunch,

Leah 33:22

know we're obviously doing this

Tina 33:23

going to work.

Leah 33:25

on the food part All right. So, so, so, okay, so, so making sure that your macronutrient and micronutrient needs are met, we are not advocating for taking a multivitamin. we are advocating for eating

Tina 33:40

But if someone wants to take a multivitamin, we advocating.

Leah 33:44

We're not advocating against it. We just don't know what's going on with everybody. And so to say blanket, like you have to be taking a multivitamin. That's not. am I speaking? I'm speaking for both of us, but you

Tina 33:56

I see. No, no, I, I totally agree. You are unlikely to do any harm with whole food diet and everything should come from the diet. Yes. Agreed. I think some people at least the short term after treatment, when you really need intensive repair and healing of tissue and getting your counts back, your blood counts, your white count and your red cell count back in that and taking a multivitamin for a short period of time. Doesn't seem unreasonable to me. and a really general multivitamin, I'm not a big fan of using mega doses of anything. Does it?

Leah 34:29

Absolutely not, me too.

Tina 34:30

B vitamins megadoses of anything, unless I know exactly why I'm giving it to that person because of their particular physiology demands that. cause when you give the high dose of any vitamin you're giving a high dose of what is basically a co-factor for a chemical reaction and by giving a high dose, can actually affect that chemical reaction in the body, such that it goes faster, it becomes more efficient. Sometimes you want to do that and sometimes you don't. So I would, I wouldn't do it Willy nilly. I would do it very selectively. And because there's a need for a high dose of a nutrient,

Leah 35:05

Yeah. I mean, I think there was like that. I don't want to say it's a fad, but there was sort of a movement for really high dose vitamins. You know, you see these capsules and it's like, take six a day. I would have patients bring me these things and they're like, I heard this was really good. It says to take six capsules a day and I'm like, the dietician tells me that you're eating well. So let's take one. That's okay, too, you know?

Tina 35:26

I totally agree. and I say B vitamins because often B vitamins come with way more than people need. like 12000% of the B12 one needs daily. I think that those can be, playing with physiology. We don't know exactly what's happening with all the high dose stuff altogether.

Leah 35:41

was another big one that people were doing for a while. So yeah, there are also some herbs and especially like when you're talking to me about the HPA access, there are supplements. I'm not even going to just category like herbs, you know, like stress, there are supplements that help to support that. I guess adaptogens is the term that a lot of people throw around.

Tina 36:02

yeah, they help you adapt to stress. So they're called adaptogens. so plants that are adaptogens, are the gin sings, you know, so whether it's Siberian, ginseng, Chinese Jensen, Korean ginseng, they're all considered adaptogenic plants. Um, Rhodiola is in there with AMIA. They all have slightly different actions, even though they're all called adaptogens. Some of them are more calming or sedating. of them are more, stimulatory. So you do need to know which one to use. Probably the one that there's decent evidence on and is probably the least likely to cause issues is American ginseng. it's a fairly neutral adaptogenic. American gin has some nice studies on fatigue during treatment, that showed that those who took American ginseng had less fatigue. Um, and we generally anyone who uses herbs knows that the ginseng plants are there for this very purpose. I mean, we, we use them to help bring that rhythmicity back that circadian rhythm back. So generally speaking, adaptogenic plants are used in the morning, early afternoon. We don't usually dose them in the evening. There are some adaptogens that are more sedating, like I said, so we might selectively do that here and there, but for the most part, when we're talking with the gin sings in particular, you're talking about early day. When you want to give support the energy processes of the body, enough cortisol during the earlier parts of the day to have energy.

audioTheCancerPod21598793371 37:27

I want to add something about starting adaptogens. When a person starts something like Ashwagandha or one of the other adaptogens that we mentioned. And remember, don't start anything without first talking to your doctor, um, don't start with like a high dose. Don't start with the big guns. Like ease in no start slow. Don't go from like zero to 60. Like you, you know, you want to definitely start with a lower dose, maybe start with something like the tea, you know, something that isn't As potent.

audioTinaKaczor11598793371 38:00

Yeah, I totally agree. It's too stimulatory for some people, if they start too quickly.

audioTheCancerPod21598793371 38:05

Yeah. And then you're just uncomfortable and then you don't want to do it at all. So it's a slow process. So, so start gentle.

audioTinaKaczor11598793371 38:13

Good point. Let's see what else.

Leah 38:17

And so one of the things that I think of also that helps to support the HPA axis is it's vitamin C.

Tina 38:24

Yeah. Especially. during severe stress, right? This is when we need more vitamin C

Leah 38:29

what I find interesting about vitamin C is that, many animals produce their own and humans and other, like a few other animals, like Guinea pigs to get it from their diet.

Tina 38:40

I did not know Guinea pigs

Leah 38:41

Oh, you didn't know that. Fun fact humans and Guinea pigs. yeah, I always thought that was really cool. So, you know, vitamin C is good for so many things, but it can also help with how the body processes, stress,

Tina 38:54

Yeah, I think it normalizes some of that feedback mechanisms where the cortisol triggers or doesn't trigger the hypothalamic pituitary axis. And so it helps normalize that during high stress, the B-vitamins that are involved are B one and B five and then L tyrasine is also, useful for fatigue.

Leah 39:12

so tyrasine is found in animal products. It's also found in nuts and seeds and whole grains, but yeah. Beef, pork, fish, chicken, tofu, dairy.

Tina 39:23

Hm.

Leah 39:24

like, I think of, for people who get really tired, like I always talk about like, oh, well just, you know, grab a snack of some raw, nuts and seeds. And so maybe it's the tyrasine that's helping

Tina 39:32

Uh huh. Maybe

Leah 39:36

So you mentioned for B vitamins, you mentioned, thymine, which is B one, which also helps with nerve function, which is nice. And then, vitamin B five, but I think a lot of people think like, oh, B12, right? That's like the energy B vitamin.

Tina 39:50

that's a good point. Yeah, people do associate B12 with fatigue or energy and it's true. One of the symptoms of B12 deficiency is fatigue And as we get older, B12 is the only vitamin that we need a cofactor that is made specifically in our stomach to absorb it when it's in our diet. Right? So there's a lot of ways of being deficient in B12 and not eating animal products at all, which is mostly where B12 is found. And two just aging and losing the ability to make what's called intrinsic factor in the stomach, because without intrinsic factor being made by the stomach, you can't absorb what you put in your mouth. So it's a common nutrient deficiency.

Leah 40:28

But not too supplement with it, unless you haven't known, deficiency,

Tina 40:32

Yeah. I would say B12 could be tested rather easily. So I would only give it if there's a deficiency, unless. Vegan or there's evidence that you don't absorb it. Right. So then, you know, you're not going to be absorbing it as you go forward, then you need to supplement it. And with B12 supplements should be either a spray or something that goes under the tongue,

Leah 40:52

help with absorption.

Tina 40:53

to make sure that it's absorbed. Yeah.

Leah 40:55

you were talking about gen sings as being supportive for fatigue and Siberia engine saying it's not actually a ginseng, right?

Tina 41:03

That's true. we call it Siberian ginseng because the other gen sings were already known to be used for endurance and stamina and the plant. That's why that was used in Siberia, which got dubbed severe. And ginseng is not a ginseng like as an a Panax species. All the other gin sings Trojans things. Start with the word panics in their name. This one's eleuthero caucus. So eleutherococcus is the actual Latin botanical terms within an eleutherococcus species, not panics species. So it's called Siberian ginseng, but it's really not related from a botanical sense. this is interesting. When herbalist practice, when you're seeing a patient, you're picking a plant that does several things at once. And so I think of Siberia and ginseng eleutherococcus when someone might have more, not just fatigue, but maybe anemia because it's known to help with red blood cell counts. And I might also think of withania for those people on with AMIA is the Latin term, also called ashwagandha. and I are Vedic medicine. Those two in particular have evidence for supporting red blood cell production. Eleutherococcus is a little more stimulating and considered a little bit more of a warming from an energetic perspective while withania is more calming, more sedating, a little more support for those who are more anxious that said withania is also in the Solon ACA. So

Leah 42:34

a nightshade family.

Tina 42:36

yes, that's the night shade. So if someone is reactive to night, shades, tomatoes and peppers and eggplant, then they may react to withania. So I would not give that particular person or with any a plant.

Leah 42:46

And in, Ayurveda ashwagandha is very supportive for people with Vata dosha, which is kind of the thinner quicker, for a person who has like more tendencies to anxiety.

Tina 42:58

Okay. That makes sense.

Leah 42:59

So it's somebody who is, you know, they're always very cold. know, they're, they're like, they're like the wind they're, they're aggravated by wind even, you know,

Tina 43:08

Okay.

Leah 43:08

that kind of, person. So just a little, a little side there.

Tina 43:12

Yeah. And one last adaptogenic plant. I want to mention, because I think there's a caveat to this one. Rhodiola is out there as an adaptogenic plant for help with fatigue and endurance and energy and particular mental energy Rhodiola, it will make its way into a lot of formulas. it also can lower blood sugar in some people. the one thing about Rhodiola is that it can cause higher anxiety in some people. And so Rhodiola is the one that I'm careful with for that reason. while studies show that it reduces, uh, mental and physical fatigue and improves energy and especially processes in the brain, it can also, exacerbate an underlying anxiety. So just be careful, a little caveat to the.

Leah 43:54

So I've seen formulas that have the different gin sings and Rhodiola. they're just kind of like the kitchen sink that probably wouldn't be. A good thing for someone to take, because one of them doesn't play nice with them, you're not going to really know which one, I mean, so do you, do you do combo, supplements with patients or do you just kind of do single

Tina 44:14

I, I will often put several plants together, but I don't usually mix my adaptogenic plants. I'll choose the one that I think is most appropriate for that person. there is someone who wrote a great book on this, uh, Veeva. Aviva Romm wrote a great book on adaptogenic plants. She was an herbalist before she became doctor. and she came up with a book a couple of years ago. I think maybe we can link to that. And, uh, it gives a good overview of all of these plants and of this whole HPA axis dysfunction that we're talking about. So I think she did a nice job on that.

Leah 44:46

Yeah. I just wanted to mention that because I think there are, you know, it's kind of a trendy thing. it's kind of a Goop thing.

Tina 44:52

shot gun approach

Leah 44:53

yeah. And so that might not, you know, maybe it'll work for a while for someone, but you want somebody who knows what they're doing to recommend it specifically for you So are there are other, supplements that can be helpful for fatigue, but those are more specific to what's going on with, with an individual

Tina 45:13

Yeah. Yeah. There's all sorts of testing. One can do to figure out their own physiology and where they might need support, organic acid tests. Popular out there. there's nutrient evaluations. You can use red blood cells or plasma or serum to do some nutritional checks. I mean, I think that you can be very specific if you see physician, a functional medicine doctor. So we're not saying, there's a pathology. We're assuming there's no underlying pathology causing the fatigue. If the fatigue is persistent, despite the fact that you've already looked at every reason possible from a disease process, then it's probably a functional issue. And that's going to be better assessed by someone who is practicing functional medicine or naturopathic medicine,

Leah 45:56

Right

Tina 45:57

So the interventions for patients. Post-treatment according to NCCN guidelines. And we talked about a lot of these, but I just want to summarize, so they put it into non pharmacological and we hit on all of those physical activity, psychosocial interventions, and that was the yoga mindfulness based stress reduction, cognitive behavioral therapy, and also the cognitive behavoiraltherapy for sleep as well. Because if you don't sleep well, you're going to be fatigued. They also mentioned the acupuncture, which we talked about nutritional measurand bright white light therapy. and that is trying to get that 24 hour rhythm by doing bright white lights in the morning. and that does make their official guidelines. And so that's another way to entrain that 24 hour rhythmicity that can be thrown off due to treat them. They do talk about some pharmacological ways of, getting your energy back.

Leah 46:48

Right. It's typically like methylphenidate, which is Ritalin or, a steroid either dex or prednisone.

Tina 46:56

yeah. And of course, you know, as naturopaths, we're going to say that's a, that's a last resort, right? You really want to having to resort to drugs, if you possibly can. And then of course, you know, treating the underlying causes, which of drugs might be there for treating underlying issues, whether it's pain or other issues that are underlying the fatigue. so that's kind of the summary mentioning everything. We, we mentioned that a couple of

Leah 47:19

So we also covered some of the various herbs that can support the HPA access, which is, one of the, big culprits when it comes to this ongoing fatigue after cancer treatment, Speaking of fatigue, we are well past our lunch hour. so I, I do want to mention our song for this episode. whereas shake it out by Florence and the machine is the song that encompasses all of the survivorship pod, exhausted by the foo fighters is the song that I chose for this particular episode.

Tina 47:55

should I know this.

Leah 47:56

No, I don't think so. I didn't really know it either.

Tina 48:00

Okay.

Leah 48:02

I just did a search and then played the song and I was like, okay, that works.

Tina 48:07

So I've got to go Spotify.

Leah 48:09

Yes. I will be putting that on Spotify. And, um, that'll get added to our playlist. And if y'all, aren't following us on social media, we're on Instagram and we're on Facebook. And sometimes on Twitter, we have a website where on occasion, we post a little interesting things. Like whether it's a recipe or, you know, teaching you something.

Tina 48:33

You don't sound very

Leah 48:34

I am fading fast.

Tina 48:39

This is hypoglycemia 1 0 1.

Leah 48:47

a lot of what we talk about, our links are in the show notes. We also have a Pinterest page that I am continuing to post links to. So kind of depends on how you like to get your information. And as always hit that subscribe button, drop a rating and a review. Tell us what you think of us. We can take it. We're grownups.

Tina 49:10

just be nice.

Leah 49:11

Always always,

Tina 49:13

don't want to take it. I want good news or no news.

Leah 49:21

oh my, okay. On that note, I'm Dr. Leah Sherman

Tina 49:25

And I'm Dr. Tina Kaeser

Leah 49:27

and this is the cancer pod

Tina 49:29

until next time