Cancer Related Fatigue with Dr. Lise Alschuler: Rational Wellness Podcast 106

Dr. Lise Alschuler discusses Fatigue in Cancer Patients with Dr. Ben Weitz.

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Podcast Highlights

1:45   Fatigue in cancer is under reported, underdiagnosed, and undertreated.  That’s because cancer doctors tend to focus on patients pain and tend not to pay attention to fatigue even though many patients report that the fatigue is their most distressing symptom. 

3:33  Cancer related fatigue is a very severe fatigue and not the kind of fatigue that you can sleep off or easily recover from. 80% or more of cancer patients suffer with this type of fatigue. Dr. Alschuler explained that “from a functional perspective, we would think of this kind of fatigue as the fatigue that is happening on a cellular or even mitochondrial level and, has really gotten to a point where it’s influenced our endocrine system. So, it’s obviously going to take quite some effort to get people out of this type of fatigue.” And for up to 50% of these patients will have this fatigue for years after the cancer is gone, and this where a Functional Medicine approach can be helpful.

5:22  Dr. Alschuler feels that most of the fatigue is related to the cancer more so than the cancer treatment, though the treatment adds to it. The mechanism is the release of inflammatory cytokines by the cancer cells or the stromal response around those cancer cells, like Tumor Necrosis Factor alpha (TNFalpha) and Interkeukin 6.  This is the initial cause of the fatigue and one of the next phases of cancer related fatigue is the circadian rhythm disruption and the hypothalamic/pituitary/adrenal access dysfunction that occurs.

7:06  Sleep is very important in being able to recover from cancer and many patient have their circadian rhythm and their normal sleep cycle disrupted, so you want to help the patient to reinstate their circadian rhythm and their normal sleep pattern.  We’ve discovered clock genes, which occur in every cell in our body and they are tied to our circadian rhythm.  These clock genes are also involved in really important things like cellular repair, cell cleanup, autophagy, so we want to have our circadian rhythm in tact. Dr. Alschuler will often measure the adrenal stress profile with the cortisol awakening response.  She will also measure cytokines, including C Reactive Protein and Interkeukin-6, which are acute phase reactants, 11-Dehydrothromboxane B2, which is a measurable metabolite of the arachidonic acid LOX and COX pathways, and 8-hydroxy-2-deoxyguanosine, which is a good indicator of oxidative stress.

12:46  Cancer and chemo both result in a lot of oxidative stress on the body, so everybody who goes through cancer and cancer treatment will be depleted of antioxidants. They need some antioxidant repletion either from antioxidant supplements or from a good plant based vegetable and fruit diet. The oxidative stress contributes to the HPA hypothalamic/pituitary/adrenal/circadian rhythm dysfunction, as well as a contributing factor to mitochondrial dysfunction, both of which are related to fatigue.

13:45 It is understood that chemotherapy and radiation use oxidative stress (free radicals) to kill cancer cells and we need to be careful about recommending antioxidant supplements while treatment is occurring.  We now have a lot of data to be able to determine which particular nutritional supplements might help or interfere with specific chemo drugs.  But it is a different story with the newer targeted drug therapies of cancer, like the molecular based, antibody based, or immuno therapies and new drugs are being released quite often. And we are still learning whether there might be interactions with natural therapies. We need to understand how each of these drugs work and how they are metabolized and then try to figure out if there is a likelihood that there might be an interaction between a given supplement and a targeted treatment. 

21:44  The best type of diet for patients with cancer is the one that is going to lower inflammatory cytokines. Intermittent fasting for 13 hours helps to lower inflammation. Fasting for a day or two before, on the day, and the day after chemo infusions helps to minimize toxicities, esp. to the digestive tract, and may improve their energy a bit.  While cancer patients should avoid a high carb diet, they shouldn’t necessarily follow a ketogenic diet.  But should make sure that they get plenty of healthy fats like omega 3 fats, though one recent study found that soy oil was better than fish oil in reducing cancer related fatigue:  Multicenter randomized controlled trial of omega-3 fatty acids versus omega-6 fatty acids for the control of cancer-related fatigue among breast cancer survivors.  Coconut oil and MCT oil also reduce cancer-related fatigue. The effects of virgin coconut oil (VCO) as supplementation on quality of life (QOL) among breast cancer patients. Dr. Alschuler also recommends that cancer patients consume high quality proteins like legumes, tofu, seeds, nuts, eggs, grass fed or wild meats, fish, and organic poultry.  When it comes to consuming legumes and seeds, one prominent Functional Medicine doctor–Dr. Steven Gundry–has been claiming that the fact that these foods contain lectins is a problem for our health.  In advocating consuming legumes and seeds I asked Dr. Alschuler if she worries about lectins and her response is “You know, there’s many thing’s we can worry about but, no, lectins hasn’t made my list recently.”  Dr. Alschuler also recommends branched chain amino acids, which have been used in several studies that show benefit for cancer-related fatigue. 

27:18  Recommended nutritional supplements for cancer-related fatigue include:  1. Panax quinquefolius (American Ginseng) when taken at a dosage of 2 gms per day during cancer treatment and continued for 8 weeks after reduces cancer-related fatigue.  2. Rhodiola rosea is an adaptogenic herb that makes cancer patients more energetic. 3. Ashwaganda is also an adaptogenic herb that may be helpful. 4. CoQ10, esp. the ubiquinol form helps with mitochondrial support, 5. Reduced Glutathione can help support the mitochondria, 6. L-carnitine helps with fatigue at a dosage of 4 gms per day, though if the patient is on ataxane chemotherapy it can make peripheral neuropathy worse and 7. Acetyl L-Glutathione may be better for both fatigue and also cardiovascular support. 

32:14  Exercise is important in rebuilding the mitochondria and their functionality.  Exercise also helps to increase hypothalamic/pituitary/adrenal resilience and reinstate the normal circadian rhythm.  It is beneficial to do a combination of aerobic and resistance exercise for at least 45 minutes per day at a level that is moderately strenuous.

34:02  Some organic coffee with caffeine or green tea can stimulate sympathetic nervous system responsiveness and help reinstate normal circadian rhythm and enhance cognition.  And both coffee and tea are inversely associated with cancer risk.


Dr. Lise Alschuler is a Naturopathic Doctor with board certification in Naturopathic Oncology and she was past president of the Oncology Association of Naturopathic Physicians. She is the executive director of TAP Integrative, a nonprofit educational resource for integrative physicians. If you use the discount code WEITZ you can subscribe for only $99 for the year.  Dr. Alschuler wrote The Definitive Guide to Cancer and The Definitive Guide to Thriving After Cancer. She sees cancer patients in Scottsdale, Arizona and is a sought after speaker at conferences around the world and she co-hosts a ratio show, Five To Thrive Live! on the Cancer Support Network. Her website is DrLise.net.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.


Podcast Transcript

Dr. Weitz:                            This is Dr. Ben Weitz with the Rational Wellness Podcast. Bringing you the cutting edge information on health and nutrition from the latest scientific research and, by interviewing the top experts in the field.  Please subscribe to the Rational Wellness Podcast on iTunes and YouTube. And, sign up for my free ebook on my website by going to doctorweitz.com. Let’s get started on your road to better health.  Hello Rational Wellness Podcasters. Thank you so much for joining me again today, and for those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and give us a ratings and review. That way more people can find out about the Rational Wellness Podcast.

Our topic for today is fatigue and cancer with Dr. Lisa Alschuler. The National Comprehensive Cancer Network says that, “Cancer related fatigue is a distressing, persistent, subjective sense of physical, emotional and, or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.”  Pain is very common in cancer and, up to 80% of patients receiving chemotherapy or radiation and, cancer survivors report that fatigue is a disruptive symptom months and even years after treatment ends. I meant to say, fatigue is a common symptom in cancer. Fatigue in cancer is under reported, underdiagnosed, and undertreated.  That’s because cancer doctors tend to focus on patients pain and tend not to pay attention to fatigue even though many patients report that the fatigue is their most distressing symptom.

Dr. Lise Alschuler is a naturopathic doctor with board certification in naturopathic oncology, she was past president of the oncology association of naturopathic physicians, she’s executive director of TAP Integrative, a non-profit educational resource for integrative physicians, which I use regularly and very, very helpful.  They have tons of great educational videos and other information, and the service also includes free retrieval of full journal articles all for the price of the annual membership, which I take full advantage of.  Dr. Alschuler wrote, The Definitive Guide To Cancer and, The Definitive Guide To Thriving After Cancer, and The Definitive Guide To Cancer is just an amazing resource and, anybody who sees cancer patients, you have to have that book as a resource.  Dr. Alschuler sees cancer patients in Scottsdale, Arizona, she’s a sought after speaker at conferences around the world, she co-hosts a radio show, Five To Thrive Live on the cancer support network and, she’s also a cancer survivor herself.  Dr. Alschuler, thank you so much for joining me today.

Dr. Alschuler:                     My pleasure, Dr Weitz. It’s nice to talk to you again, its been a while so, looking forward to it.

Dr. Weitz:                          Absolutely.  So, what are some of the reasons that cancer patients get fatigue?

Dr. Alschuler:                     You know it’s a really, first of all, I want to just emphasize the introduction that this kind of fatigue is not the kind of fatigue that maybe we all think of. Like, the fatigue that we get when we’re working too hard and, we just need to sleep in on the weekends and then, we kind of wake up rejuvenated. This is not a fatigue that people can sleep off, it’s not something they can recover from, it’s a very debilitating fatigue and, it’s associated, actually, with anxiety, with depression, with cognitive dysfunction. It’s a very, so, it’s a very deep seated fatigue.  I think, from a functional perspective, we would think of this kind of fatigue as the fatigue that is happening on a cellular or even mitochondrial level and, has really gotten to a point where it’s influenced our endocrine system. So, it’s obviously going to take quite some effort to get people out of this type of fatigue.  But, so I just wanted to really emphasize this type of fatigue is quite different and, as you said, the majority of people going through cancer and treatment, upwards of 80% have this kind of fatigue. It may not be severe, it may be sort of mild but, even mild cancer related fatigue is pretty significant and, some people fortunately probably over half do kind of spontaneously, as we would say, their innate healing process takes over and they can overcome the fatigue, maybe six months out from their diagnosis but, the rest can have it for years and, years and, years.  So, this is something, I think, our prime opportunity for integrative practitioners to really jump in on. And now that I’ve taken us on this tangent, I don’t even remember your question.

Dr. Weitz:                          That’s great.  How much of fatigue do you think is related to the cancer versus the cancer treatment?

Dr. Alschuler:                     Yeah, I think that the majority of fatigue is related to the cancer and, I think that the treatment is basically jumps onto that.  The reason I say that is, because there seem to be some emerging underlying mechanisms that are becoming commonly accepted. So, one is, that there’s clearly a cytokine aberration in cancer related fatigue. We think that it probably is, that sort of the main culprit is high levels of Tumor Necrosis Factor Alpha and, then along with that, of course, that Interleukin six, those two, when they’re in high levels, the classic symptom is fatigue.  So, there’s definitely something to do with cytokines and cancer when you have the malignancy, there is cytokine aberrations as a result of the malignancy, either the malignant cells are secreting these cytokine’s in high levels because of up-regulated NF Kappa B in those cells or, and, or the stromal response in and around those cancer cells, there’s a high level of inflammation.  So, I think it’s mostly the cancer but, you take that kind of inflammatory, simmering mix and, you throw some chemo in there and, you’re just going to aggravate those inflammatory cytokines.  One of the next phases of cancer related fatigue then is, the circadian rhythm disruption and the hypothalamic/pituitary/adrenal access dysfunction and, that system, as we know, is also very sensitive to cytokine induced oxidative stress. So, I think that that’s kind of a secondary event in the continuum of cancer related fatigue. 

Dr. Weitz:                           So, you mentioned the circadian rhythm and, cancer patients often have trouble sleeping, either as a side effect of treatment or, due to stress or, due to other factors. What role does sleep play in this?

Dr. Alschuler:                    Yeah, it’s a really important point.  So, as I mentioned earlier, if somebody has cancer related fatigue and, they just say, “Okay, I’m just going to sleep for eight hours a night,” they still may have cancer related fatigue if the mitochondrial dysfunction is not addressed, if the inflammation isn’t mitigated and, if the circadian rhythm isn’t reinstated.  That being said, all those three things won’t do anything for somebody if they’re not sleeping so, sleep is essential, it’s an essential component to recovery and, as you mentioned, a lot of people go through this disease and treatments because their circadian rhythm is so disrupted and, so shifted their sleep cycle gets very disrupted as well.  So, one of the key cornerstones, if you will, of addressing recovery and survivorship is to reinstate circadian rhythm and, as a component of that, sleep.

Dr. Weitz:                            So, let’s say the person normally wakes up every day at 6:00 or 7:00 or, 8:00 in the morning, goes to work, goes through their day, et cetera, et cetera. Now they get cancer and, maybe they’re off work and, their schedule changes so, it kind of throws their circadian rhythm off. Is it better for them to just go back to waking up every day at 7:00 and, having their regular schedule? Is that something that’s beneficial?

Dr. Alschuler:                     Yeah, I think it is. There’s, you know, now that we’re learning more about the circadian rhythm, I think that we understand how sensitive it is to what I call, ritual and rhythm and, the more ritual and rhythm we have in our day-to-day lives, the easier it is for us to have a healthy circadian rhythm.  And, remember, that even within the last 10 years, we’ve just now discovered clock genes, which occur in every cell throughout our body, are directly tied to the circadian rhythm. They only function or turn on in accordance with the circadian rhythm and, most of the genes controlled by clock genes are involved in really important things like cellular repair, cell cleanup, autophagy, so we want to have our circadian rhythm in tact for lots of reasons, that being the primary one.  So, yes, to go back to your question, if somebody had kind of a rhythm, ideally a rhythm that were used to, now they’re off work, their rhythms kind of all crazy, it would really be helpful to try to go back as closely as possible to what they had before, assuming that that rhythm was optimal for them.

Dr. Weitz:                            When you’re treating a patient who has cancer related fatigue, do you, when you work them up, do you try to sort through which, you know, what are some of the causes of the fatigue?  Like, for example, do you measure cytokine’s, are there certain questionnaires you use?  Do you try to figure out how much is hormonal, how much is related to different factors in coming up with a treatment plan?

Dr. Alschuler:                     Yeah, I often do.  You know, not 100% of the time if I have a good kind of, I don’t know if it’s intuitive hit or, just having done this for a while hit but, if I’m really wanting to be very precise then, yes.  So I’ll do an adrenal stress index test and measure cortisol at four points over the 24 hour period. Get a really good sense of their cortisol awakening response, as well as their full circadian rhythm and then, I do often …

Dr. Weitz:                            That’s just, that’s the new part of the adrenal stress test, is the cortisol wakening response where you are measuring how their cortisol changes in the first 30 minutes after awakening.

Dr. Alschuler:                     Yeah, haven’t seen a normal one yet but, I’m still holding out for it.  But, I think it is important, this is really actually a pretty substantial body of literature just on cortisol awakening response in relationship to depression and, anxiety and, all sorts of things.  So, yeah, adrenal function, for sure. I do measure cytokine’s for this purpose and also, just as a way to assess, to some extent, what’s the milieu of this person like so that I have a, kind of I can determine whether or not they are more or less at risk for occurrence.  So, for cytokine’s, I will most commonly measure include C reactive protein as an acute phase reactant, Interleukin 6, I definitely look at and, those two alone are usually enough to do it. There’s another inflammatory test that I have started to use quite a bit, it’s a urine test and, it measures 11-Dehydrothromboxane B2, which is a measurable metabolite of the arachidonic acid LOX and COX pathways.  So, it’s a very important way to assess the eicosanoid side of inflammation, and then the CRF and the IL-6, sort of measure the genetic side of the inflammation, the NF Kappa B, up regulation side so, all that together can give me a pretty good sense of what’s going on.  And then sometimes I might also look at, see if there’s any evidence of oxidative stress, which would be another indication of the fact that there’s up-regulated inflammation so, looking at 8-hydroxy-2-deoxyguanosine would be kind of my go to.

Dr. Weitz:                            Okay so, oxidative stress means that there’s not enough antioxidants to block some of the excessive oxidative stress.  And, of course, oxidative stress is often part of the chemotherapy if they’re getting chemo.

Dr. Alschuler:                     Yeah, most everybody who goes through cancer and its treatments will be depleted from an antioxidant perspective at the conclusion of that treatment.  So, typically, some degree of repletion is necessary.  It doesn’t necessarily have to be supplementation, a good plant based vegetable and fruit rich diet can restore people’s antioxidant capacities but, yeah, it’s very common and, that oxidative stress is a contributor to the HPA hypothalamic/pituitary/adrenal/circadian rhythm dysfunction, as well as, a contributing factor to mitochondrial dysfunction, both of which, as we talked earlier, are related to fatigue.

Dr. Weitz:                            I know we’ve discussed this in the past but, where are we in terms of the use of antioxidants during cancer treatment?

Dr. Alschuler:                     You know, again, I think that the controversy, I will say is a little bit muted right now and, maybe because we’re starting to get a little bit more savvy and realize that when you say, antioxidants, we’re talking about such a large and diverse group of compounds, some of which are problematic with certain chemotherapy agents or, certain radiation treatments, some of which are actually very helpful.  So I think we have to sort of say, the question shouldn’t be, are antioxidants safe or not? The question should be, can I use X, Y or, Z?

Dr. Weitz:                            Right.

Dr. Alschuler:                     Then we have data now to answer that very specific to the actual treatment that somebody’s getting, the cancer type even and, figure out, yeah, you were a prime candidate for using this antioxidant or, nope, this is not good for you.

Dr. Weitz:                            Okay, good, good, good.  And, does that apply to the newer drugs, the targeted drugs?

Dr. Alschuler:                     So, you know, as you mentioned, cancer treatment is changing and, hopefully, some day, chemotherapy will be a thing of the past but, we’re not quite there yet.  But, more and more we’re moving towards molecular based therapies or, antibody based therapies or, immuno therapies so, these all target tumors in one way or another by either, capitalizing on a genetic aberration in the cancer and targeting that very precisely or, by stimulating our own innate healing mechanisms, like the immuno-therapies are essentially un-breaking the immune system to attack.  And, we’re getting a lot more sophisticated with all this now. Because this is all new and, it’s happening so fast and, there’s new drugs in trial all the time, we, in the integrative space, are playing catch up, for sure and, we just are really in a place of trying to understand what we have that’s helpful, not contraindicated.  Generally speaking, this is an area where it would really be important to be under the care of an integrative practitioner with an expertise in integrative oncology because, like even me, when I had a patient that, and that’s all I do is, integrative oncology and, when I have patient, I get patients every week with new drugs I haven’t heard of so, I have to go, I have to research the drug and, really understand its mechanism, it’s metabolism and then, I have to apply that with a knowledge of it’s side effect profile, figure out what I have to use, see if there’s any potential for a reaction and, be very cautious around that whole thing. So, it takes a lot of time and effort so it’s not, you know, we’re still learning, that was a long-winded answer.

Dr. Weitz:                            You know, I was looking at some studies on some of this stuff and, a couple of the papers were mentioning the part of the cytochrome P450 pathway that this nutrient affects and that could interfere with this drug. And you start going, oh my God, you can’t take this, you can’t take that and then you start looking at the drugs and you realize that this cocktail of cancer drugs are actually interfering with each other.  And, you know, nine other things that they’re taking to control their blood pressure and, everything’s interacting on these cytochrome P450 pathways and so, it occurs to me that, if you use that as the basis for not eating something, it’s way to complicated to use that as a rule out, don’t you think?

Dr. Alschuler:                     Well, I think, so eating for sure but, I think that with supplements the challenge is that, so, yeah so, first of all, a good practitioner, conventional practitioner will do a drug/drug interaction check when they’ve introduced chemo to make sure, because, and sometimes I’ve seen patients get pulled off of pre-existing antihypertensive drugs, or whatever, because of potential interaction.  That being said, there are some that are left but, the degree of the interaction can really vary so, it may have a little reaction but, it’s not clinically significant. So a lot of the nutrients in herbs, the data we have is pre-clinical and, that has almost no relevance to what happens in the human.  So, really, I look for human pharmacokinetics studies so that I can see, is there really a potential for interaction here?  And, that being said, if somebody’s on a small targeted molecule type of therapy, which has a very small dose and, a very narrow, kind of a very, the blood dose, the concentration that is targeted is very narrow, I don’t want to mess with that because, if I mess with that, I could run the risk of increasing side effects and, you know, who knows what.  So, you know, in general it’s best to be cautious with drugs that have a high percentage of toxicity.

Dr. Weitz:                          Right, okay.  So, back to the fatigue. What role does anemia play, which is a common side effect of a lot of chemo?

Dr. Alschuler:                     Yeah so, it’s a really good point.  So, generally speaking, when we’re talking about care to related fatigue, that’s, in medical kind of perspective, that has the assumption that we’ve ruled out known causes of fatigue.  So, if somebody comes to treatment, I’m tired, you need to check, are they anemic, do they have thyroid dysfunction or, are there any other obvious causes of fatigue and, obvious nutrient deficiency, for example? Address all that and, if that takes care of the fatigue, we’re good, if they’re still tired, then they have this cancer related fatigue.

Dr. Weitz:                            Do you have a certain panel you like for assessing nutrients because, there’s a lot of controversy as to the best way to assess nutrients because, a lot of times just serum levels are not indicative of tissue levels, et cetera.

Dr. Alschuler:                     Yeah so, I don’t run serum vitamin levels except for vitamin D and, vitamin D deficiency is associated with fatigue so, that’s one that we want to check.

Dr. Weitz:                          Right.

Dr. Alschuler:                     I do look at red blood cells zinc, red blood cell magnesium, I think those are very accurate and nice reflections.  To get at B vitamins in general, I typically run a urinary organic acids test.

Dr. Weitz:                          Okay.

Dr. Alschuler:                     Yeah, which kind of looks at the metabolites from the TCA or the Krebs cycle where, we use the vitamins to make energy so we can tell by the ratio of metabolites whether we’re lacking certain B vitamins or, we have kind of a blockage in that pathway.

Dr. Weitz:                          Yeah.  Have you used the NutrEval? Do you like that test?

Dr. Alschuler:                     I have ordered that on occasion and I think that it is, it provides a really broad view of nutrients, nutrients status so, I think it can be helpful.  I’m not 100% sure and, this could just be my ignorance, the data but, I’m not 100% sure that that snapshot in time is truly representative of an ongoing functional deficiency that’s related to symptoms or, pathology.  So, I’m not sure how actionable some of that information is. And there’s always a range so like, what’s really the cut off? You start to, what indicates, yes, we need to give this person this supplement.  So, I still have some questions around that but, I think it could be a guide.

Dr. Weitz:                          Yeah, because it includes an organic acids and then, there’s also some red blood cell minerals and so, throw in some other stuff.  So, what type of diet?  So diet is very controversial when it comes to cancer and, when we have patients with cancer with fatigue, you want to make sure they’re getting the right nutrients to give energy. We often think of carbohydrates for energy but, these days, one of the more popular strategies for dieting cancer is to use a lower carb approach, a ketogenic approach, maybe intermittent fasting.  What’s your take on that?  How does that interact with fatigue?

Dr. Alschuler:                     Yeah, excellent question.  So, with cancer related fatigue, again, because it’s primarily a cytokine disorder, the diet interventions that are going to lower inflammatory cytokine’s are going to be the ones that would be most effective.  So, for example, intermittent fasting, we know lowers CRF, sorry, high sensitivity to reactive protein. So, we know that when we intermittent fast, we lower inflammation in the body so, that’s a perfect dietary strategy for somebody with cancer related fatigue. My goal is 13 hours as an overnight fast, anything above that, bonus but, 13 hours is kind of the magic number from a research perspective. And then, beyond that …

Dr. Weitz:                          What about fasting, some clinics are recommending fasting the day of chemo, maybe the day before, the day after or, some level of complete fasting all centered around when they get their chemo.

Dr. Alschuler:                     Yeah, so that’s kind of a separate strategy in terms of minimizing some of the toxicities from the chemo, particularly to the digestive tract.  It does appear, maybe, in some people to also improve people’s energy a little bit within the time of getting chemo, whether that has any impact on post treatment, cancer related fatigue is, to my knowledge, not known. I haven’t personally observed a strong correlation there. But, it may, I don’t know.

Dr. Weitz:                          Okay. I’ve thrown you off track.

Dr. Alschuler:                     Yeah, no, that’s fine.  But, yeah, post treatment, I think, intermittent, overnight fasting, definitely. I would not go for a high carb diet unless you’re talking about complex carbs from vegetables through whole grains but, simple carbs, although they give us immediate energy, are very oxidative over time.  So, that’s going to worsen the cancer related fatigue. So, really what’s more important is, two things. Number one, fats and, it doesn’t have to be necessarily a ketogenic diet but, we know that omega three fatty acids and, actually there was a very recent study that somewhat surprisingly found that soy oil was more effective than fish oil in reducing cancer related fatigue.

Dr. Weitz:                          Really?

Dr. Alschuler:                     Yeah, which is kind of crazy that they attributed that to the soy oils content of omega six and omega nine.

Dr. Weitz:                          What?

Dr. Alschuler:                    And that that had a decreasing effect on tumor necrosis factor alpha.  Kind of interesting, I don’t know, its just sort of an outlier for me but, I think really what it speaks to is, we need good fatty acids, that our body needs.

Dr. Weitz:                          Was that study funded by the American Heart Institute?

Dr. Alschuler:                     No, I don’t think so.

Dr. Weitz:                          Okay.

Dr. Alschuler:                     And, the other things so, fatty acids so, fish derived fatty acids for sure.

Dr. Weitz:                          Coconut oil, MCT oil.

Dr. Alschuler:                     Coconut oil, yes.  I think that, actually, has been studied and seems to improve cancer related fatigue.  And then, protein, you know, people really need a lot of protein. The range, generally is, just for an average person is like point 0.6 to 1.2 kilogram or, grams of protein per kilogram of body weight so, after treatment, I go to the high side of that. 1.2 grams of protein per every kilogram of body weight and, try to get people eating really high quality protein.  And so, high quality protein, high quality fats, overnight fast, from a dietary perspective, are kind of the keys and then …

Dr. Weitz:                          When you say, high quality protein, you’re advocating animal products, right?

Dr. Alschuler:                     I’m fine with animal products, you know, I think that if so, high quality proteins for me, for my vegetarian perspective include, legumes, tofu, seeds, nuts, eggs. And then, from my non-vegetarian perspective, grass fed or wild meats, fish, organic poultry.

Dr. Weitz:                          Okay.  You worry about lectins?

Dr. Alschuler:                     You know, there’s many thing’s we can worry about but, no, lectins hasn’t made my list recently.

Dr. Weitz:                          You mentioned protein, I saw one of the studies used branched chain amino acids as part of the protocol.

Dr. Alschuler:                     Yes. I think branched amino acids are really helpful for cancer related fatigue and, I think that that’s probably where supplementation is the easiest way to get that in.  So, getting a protein powder with a good whey or, amount of branching amino acids, people can really subjectively feel the difference pretty quickly with that.

Dr. Weitz:                          So, which nutritional supplements can be beneficial for patients with fatigue, cancer related fatigue?

Dr. Alschuler:                    So, from a, there are many, first of all and, the first thing that comes to mind, of course, when we’re thinking about circadian disruption are, adaptogenic herbs. And there was actually a really nice study that was done using Panax quinquefolius so, American Ginseng, specifically on cancer related fatigue and, they started the Panax quinquefolius, it was, I think two grams a day during the treatment, and then they continued it beyond treatment for eight weeks and, there was a substantial reduction in the degree and, the severity of the fatigue and people taking the Panax quinquefolius and so, that really just speaks to the role of preserving the circadian rhythm, which is one of the things that these adaptogenic plants do.  So, I use Panax quinquefolius, American ginseng, often. I also use an adaptogen called, Rhodiola rosea, which is, although adaptogens aren’t sort of like energy pills, there are some adaptogens, which are a little more energetic than others and, so Rhodiola is one.  It just really increases people’s physical stamina, their mental clarity so, I find that very helpful.

And, there’s also adaptogenic blends, which work beautifully for people. If people are really depleted, really depleted coming out of therapy, I’ll probably start a little more gently, something like, ashwagandha and, you often dose that at night because, it has a little bit of a sedative effect to it.  So I definitely use that. Then I think about mitochondrial support and, you know, mitochondrial support can get very complicated but, I think, fundamentally, CoQ10 is critical and, I happen to favor, ubiquinol as the form of CoQ10 and, I dose it pretty aggressively so, I’m giving people 100 milligrams, two or three times a day to really try to get their CoQ10 levels up and, to try to improve their mitochondrial health. Because, the mitochondria themselves become oxidized and, they need to get that redox balance back.  Along those same lines, I’m also a fan of glutathione and I will use glutathione, reduced glutathione post treatment.  That’s not something I use concurrent with treatment but post treatment, to help replete people’s redox potential or, antioxidant levels. Typically dose that in the morning and, that can be quite helpful for people too. And, that supports, of course, mitochondrial function.

Dr. Weitz:                          You like a liposomal form?

Dr. Alschuler:                     You know, I don’t need a liposomal form, actually, there’s some good data by a researcher, by the last name of Ritchie, at Pennsylvania, Hershey State, the University of Pennsylvania, I can’t quite get his university quite right but, he really eloquently demonstrated that glutathione is very well absorbed orally and, it increases glutathione levels in various bodily compartments in accordance with the dose. Doesn’t need to be liposomal.  Liposomal, I think, probably does enhance the glutathione absorption even more so, especially if there’s compromised intestinal integrity, which often is another sequelae of chemo, for example or, radiation, then liposomal might be even better.  But, you know, it’s a cost issue, whatever, I think just straight up, reduced glutathione works well.

Dr. Weitz:                           L-Carnitine?

Dr. Alschuler:                     Yeah so, L-Carnitine’s a good one, you know it’s been studied and it for sure reduces fatigue, particularly kind of muscle fatigue.  And it’s particularly good for people who have had radiation and, L-Carnitine is effective but, it needs to be dosed the four grams a day. Anything less than that just doesn’t work.  The challenge with L-Carnitine is that, if somebody’s had ataxane chemotherapy, it can make peripheral neuropathy worse. So it’s contraindicated in people who have had ataxane chemotherapy.  Other people seem to do fine with it.

Dr. Weitz:                          Is that just Acetyl L-carnitine or, does it not matter?

Dr. Alschuler:                     No, it’s all of it, all carnitine and acetlyl L-carnitine.

acetlyl L-carnitine is the one that I use when I want to address the fatigue and I’m also concerned about heart function, which I didn’t really speak about, it can be another contributor to fatigue. There are some cardio-toxic both chemo’s, some radiation and, even in these targeted therapies or, hormonal therapies that can make it a little harder for the hear to function optimally.  So, supporting heart with CoQ10, acetlyl L-carnitine can be very effective.

Dr. Weitz:                            Good, interesting.  What about exercise recommendations?

Dr. Alschuler:                     Oh, I’m so glad you asked.

Dr. Weitz:                            I remember going, I met you at that 2010 Institute of Functional Medicine conference about cancer and, I think Keith Block showed a video of patients rollerskating attached to their getting their chemo infusion at the same time and, he had a treadmill in his office and the patients were on the treadmill getting their infusions.

Dr. Alschuler:                     Yeah so, exercise is absolutely critical.  So we know that exercise rebuilds mitochondria and rebuilds their functionality. We also know that exercise helps to increase hypothalamic/pituitary/adrenal resilience or, reinstate circadian rhythm. So, I’m very specific about my exercise recommendations for cancer related fatigue.  So, most people are very tired and it’s hard to exercise so, I talk to them about figuring out where their fitness level is, being right on the edge of their fitness, exercising at that edge and then, continuing to move that edge out so that they’re getting more and more fit.  But they have to be reasonable, start where they are and then just keep pushing.  So, that exercise, as I say, should always be fun and never really easy.  And, what we know from a data perspective is that, people who exercise aerobically and, actually a combination of aerobic and resistance exercise, it seems to be for at least 45 minutes a day, at a level that’s moderately strenuous or, strenuous to them, at least five days a week, have a much lower duration and severity of cancer related fatigue.  So, exercise is absolutely an evidence based, very effective recommendation.

Dr. Weitz:                          Great.  What about a little bit of caffeine from organic coffee or, green tea?

Dr. Alschuler:                     Yeah, I’m all about it.  Not only because caffeine in, as you said, a little bit so, you know, in the morning, not kind of getting too much stimulation to the nervous system towards the end of the day but, in the morning, caffeine not only helps to in some ways actually reinstate circadian rhythm by creating that sympathetic nervous system responsiveness but, caffeine and coffee, both and, tea, are inversely associated with cancer risk for almost every cancer that we study.  So, coffee drinkers have a lower risk of occurrences, therefore and, plus, from a botanical perspective, coffee has been used to address people with mental fuzziness so, it’s a cognitive enhancer and, that’s one of the symptoms of cancer related fatigue.  So, coffee’s also going to help stimulate cognition.  So, yes, I think it’s actually very medicinal suggestion.

Dr. Weitz:                          Great so, thank you so much for spending some time with us, Dr. Alschuler. How can listeners get a hold of you to find out about your programs?

Dr. Alschuler:                     Yeah.  Well thank you for having me, first of all and, I’ll give a couple of things for listeners.  For practitioners, you mentioned TAP Integrative, I really encourage you to check it out. TAPintegrative.org. And, if you use the code, WEITZ, then you get your membership for only $99.00 which is an awesome deal.  Clinical protocols and all that stuff and, Dr. Weitz doesn’t make any commission on that, just so you know, it’s just, it’s because we love him.  So, yeah, TAPintegrative.org, you can send, find me on that site as well. There’s place to shoot an email there.

And then, for patients, I think you mentioned our radio show, which is, Five to Thrive Live and, that’s now streamed on iHeart and, Spotify and, so that’s easy to find.  And then we have a personalized online cancer survivor program, which I really encourage people to check out. It’s actually available now through AICR, which is really cool and, you can also find it directly on, ithriveplan.com.

Dr. Weitz:                          That’s great.  Thank you, Doc.

Dr. Alschuler:                     Thank you.


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