Five to Thrive Interview with Dr. Bier

The podcast of this interview can be found on iHeartRADIO.

Informed Oncology: Risk-Benefit Approach

FIVE TO THRIVE INTERVIEW with Dr. Bier January, 2020

Dr. Alschuler:
Welcome to Five to Thrive Live! The topic of the show tonight, which is really interesting and I would argue a very important topic, is developing what we're calling a risk-benefit approach to individualizing Cancer Care. This is particularly relevant of course to people who are using an integrative approach. Tonight's Five to Thrive Live guest is Dr. Ian Bier. Dr. Bier began his undergraduate work in chemistry, and earned a Master's in Acupuncture and a Naturopathic Doctorate at Bastyr University. He completed a Family Practice residency at Southwest College of Naturopathic Medicine and also completed a PhD in Human Services from Capella University. With over 25 years of experience in clinical research and academic positions, he strives to use evidence-based medicine to guide clinical decision making, and it's really going to be tapping into that experience that will guide our show this evening. So with that being said, let's jump right In.

Dr Alschuler:
Dr. Bier, welcome to Five to Thrive Live! As I mentioned to you before we went on live I'm excited to have this conversation with you and expecting to learn quite a bit from you. You clearly have a great love of science and also of natural medicine so my first question is kind of a general one: Do you consider science and natural medicine to be compatible with one another?

Dr. Bier
Absolutely! As you mentioned, my background is biochemistry. Scientific training is really learning to look at the world in a very specific way -- recognizing patterns and then testing them, and seeing what outcomes you get. So if you're being scientific in your study of the effects of a drug, a chemical, physics, or a natural substance and what it does on health it’s really the same process.

If we look at the conventional literature, it's changed tremendously in the last 15-20 years. I have a database specific to natural medicine and cancer from the conventional medical literature sources and we are currently at over 60 thousand articles, so there is an incredible amount of information. I actually looked this up the other day and when we were in medical school [in the early 90s], there were about 12 total articles on curcumin and cancer, and today I have over 5000! A crazy increase, thankfully, of information available, so absolutely.

And I think it’s also important to recognize that medical education, whether that is conventional medicine or alternative holistic medicine doesn’t really give much training in research and statistics so doctors might be great clinicians but they're rarely good scientists.

Dr Alschuler:
Right! So that's one issue, which is the tsunami of information that you just described, then we have these clinicians, as good as they might be, trying to manage that and figure out how to move forward in a way that is going to best benefit their patient. Cancer care itself is particularly complex and I have talked to my patients about the fact that there are very rarely clear right and wrong answers, but that most of the answers or the next steps are really trying to determine really a shade of gray, not a black-and-white type situation. But to manage that complexity one of the best things they can do is to be informed and I think the point you just made is that that's also true for clinicians. So what does an informed approach consist of for a patient?

Dr Bier:
The way I define Informed Medicine is really getting the proper information to make a risk-benefit balance and informed decision, no different than you do quite frankly when you choose to buy a car or house. It’s understanding what the best decision is for that particular unique individual based on the best information that's available at the time.

The concept of informed consent as we know it today in medicine is actually relatively new -- it wasn’t really talked about in the medical literature until about the ‘70s -- so I think we're still trying to all figure out what it means beyond just giving people that piece of paper that nobody really reads any more then we really read what’s given to us on the internet that we click through and say, “Yeah, yeah, I accept that.”

It’s what are you actually talking about as a risk or a possible benefit when you decide to do chemotherapy, radiation, surgery or take a diabetes medication? Is that a risk-benefit balance that feels right to you with your goals in terms of your health care journey? I am hopeful that over time this will evolve into more of a serious dialogue between the doctor and the patient taking into account who that person is rather than the kind of pro forma ‘sign this piece of paper.’

Dr Alschuler:
This is an important concept, so I want to just go over this a little bit and belabor it again. Especially in oncology, many of the treatments that are offered conventionally have significant risks associated with them and the apparent benefits may appear to be fairly light, but there is sort of that third player, I would argue, in this conversation which is that risk-benefit analysis, if you will, in the context of the seriousness or the gravity of the disease itself. In other words, if I am trying to figure out the risk or benefit of an approach for some tension headaches once in awhile, my tolerance is going to be perhaps a little different than if I'm dealing with pancreatic cancer. So I'm wondering if you can describe in a little more detail how you begin this conversation, and how you guide this conversation specific to the context of cancer.

Dr Bier:
It's a great question and I agree completely with you that it’s a very complex and difficult topic. When I am with a patient we spend a good couple hours, two and a half, sometimes upwards of 3 hours, and the vast majority is discussion. I'm trying to understand and reflect back to that person what their goals are, what I am hearing them say their goals are. Obviously, our goal with treating cancer ideally would be to make that cancer not be a part of that person’s life. But if they are dealing with an advanced cancer or a pancreatic cancer in any stage beyond really early, unfortunately that's not necessarily a realistic option.

We need to look at the process carefully in there but inherent in your question there is a fundamental aspect which is whether it’s an incredibly serious condition or a relatively simple one the outcome you desire still needs to be your focus. What I see is very often people's attitude -- (either the patient, the family, or the practitioner), if it's not serious at all you can try that other stuff but if it's really serious you need to do X, Y, or Z like the chemo, the radiation, or the surgery. What I try and get people to understand is the gravity of the situation tells you how seriously you need to take your decision. But it doesn't automatically mean telling you what decision you should make. In other words if my best option is NOT to do that therapy even if the outcome is a very bad one it's still not a good option. If it doesn't give me a positive outcome in the way that I would like it to then sometimes it's a better option to not do that thing, which is very, very difficult for people because everybody wants to feel like they're doing something.

Again, I try and help people understand, based on what they tell me they're interested in and what they tell me their goals are. If you said to me that your goal is quality of life and this suggested treatment may potentially negatively impact it, it's an open question. I have to say, “so,what I hear you saying if we are speaking to the issue of quality of life without extending your life, then is this a treatment you want to be doing?” It’s an open question.

Dr Alschuler:
What I hear you saying which is a really important point, is that this whole conversation revolves around the patient's needs and their self assessment about what's important to them, because that really is the context with which we can approach this conversation. The reality is even when you’ve broken it down to a kind of a risk-benefit conversation, those risks and benefits are relative and they're statistically nuanced and you know people who are diagnosed with cancer of course they're going to be optimistic and if there's a 2% chance something’s going to work they're going to think, “I might be in that 2%.” So, I think there's just this incredibly challenging conversation with those additional nuances. I want to throw back to you and say this conversation, I find in my practice, gets increasingly complex the more that people are involved in it, the more that they are living with cancer, the more the treatments evolve. So how do you manage this over time with all of that nuance?

Dr. Bier:
I use as a metaphor and I find that thinking of it almost like an investment; I say we’re looking at balancing your savings account if you will, and we're trying to understand the risks and the benefits of different investments in your health: good sleep, good food, good love, good people around you; and then the expenses of doing things to your body; and so you need to keep your eye on the goal, which I think is the hardest piece - once they made a decision they want to feel comfortable with sticking with that decision. What I try to get them to realize is that just because your decision to not to do chemotherapy in December was the right decision for you then it may be a different decision for you today; there may be new data out there, you may feel differently, we may have new data from your lab work or you may have a new priority. At the extreme ends of the spectrum I've had people where they basically said to me that they're willing to be in bed miserable 23 and 1/2 hours a day in order to make it to an event - Christmas with the family, or the graduation of a child or a grandchild. And I have other people who’ve literally said thank you very much I'm going to my cabin in Vermont and I'm going to go paint and I am not wasting a moment of my quality of life or time.

Both are valid goals, it's just remembering that what I might think I might choose to do if I were in their situation shouldn't be projected on them. My role is to help, to try to understand what their ultimate goal is. Again knowing the true ultimate goal is not necessarily what we may get, but how to balance the risks and check in with them and say ‘what you had told me was this was your ultimate goal and this is what you want the balance to be. Is this still true for you? Or, has something shifted? Or are we just on a path and once we're on it we kind of forgot that we were on it for a reason other than here we are.’

Dr Alschuler:
That makes a lot of sense.
You mentioned that sometimes people make a decision and then they just for whatever reason feel that the decision is made, that they’ve passed that point, and they're stuck on this path. I think that oncologists by and large are very good at explaining the risks and benefits of the treatments that they recommend to patients. I'm not aware of many patients describing to me encounters with oncologists that consists of taking the decision about a treatment and putting it in context of other decisions once they've already been started on that treatment unless they're not responding or something like that but just kind of doing what you just talked about just this continual checking in, and re-evaluating. So I'm wondering if there are ways that you have encouraged your patients, or strategies that you’ve given them, to open up this dialogue with their oncologist?

Dr. Bier:
Unfortunately, I haven't had the experience that patients are coming in with a real clear understanding of the side effect potential and the efficacy potential. As human beings, as clinicians, we’ve all had the experience when we thought we were 100% clear with people and then we hear back from them or someone else what they thought they heard us say and we say, “Really?” So I'm not blaming any other doctor or physician that they didn't [have this conversation]. I just know that the majority of patients who come to me don't have a real good sense of what the chance of efficacy of the therapy is and what the side effects are. They have a very vague sense of it, like they may be nauseous or have this, and for some people that’s all they want.

I ask people on my intake, “How much information do you like?” “I am a detailed person," or “I want a vague understanding,” or “I don't want to hear any numbers at all.” I ask them how exactly they like their information and how blunt they want their information. Some patients tell me to stop getting them fluffy bunny stuff and just tell them exactly what it is and other people are like “I get very stressed and let’s just talk around it.”

I think patients need to recognize that they are the leader of the team. I try to get people to understand that, again using the metaphor, if I said to them to give me your life savings and I will invest if for them, they would laugh at me. They would say “tell me what you are going to do, when you are going to do it, the chances of it working for me!” They’re like, “I don't release everything I've worked for my life easily!” Similarly with doctors I tell people ‘I work for you so you need to make sure I have answered your questions and you need to make sure I have helped you fulfil your goals’, and the same is true of your other practitioners.

Dr Alschuler:
Just listening to you-- kinda feeling my shoulders relaxing, and thinking that actually sounds really comforting almost even in the way that you even individualize the way you have the conversation. I am wondering if you can give a hypothetical example of cancer - let’s just take breast cancer. I just went to the San Antonio Breast Cancer Symposium and there’s a lot of data that was presented and there's some exciting new developments, but the gains at this point for some of these new therapies are very modest. Sometimes we’re seeing just a few more months of survival, sometimes it's double survival in very advanced disease but in advanced disease even though that may just translate into four or six months, that’s significant. But you know if you step back away from the data and you kind of look at it from a bigger perspective that you’re advocating, you have to ask what's the cost to get that and is whatever the cost worth that four to six months? I think that the Medical Oncologists who were at this conference, by and large, given the questions, were kinda asking themselves the same things. This is exciting yet you know this seems like there's some modestness here and what do we really counsel our patients to do around this? I am just wondering how you in the context of oncology which is changing now and a lot of the celebrated gains are just very modest, how would you have that conversation again if you want to take the example of metastatic breast cancer to construct an answer that would be fine.

Dr Bier:
When we started practicing it was enough to memorize the information, get some journal articles every once in awhile, and you’re an authority. Today the pace of information is just astounding - it just doesn't stop and it’s accelerating more and more. Over the last bunch of years what I have come to is what I call it my homework. I tell my patients that they're giving me homework and if there is a situation where it's been more than a couple of weeks since I have looked at the literature, I look at it again. Very often with patients, if they’ve got a detailed question on what the efficacy of a new therapy is or the new immunotherapy or a new combination therapy, very often I will give myself homework and put in a few hours, and I will pull the information from the literature and I will look at the San Antonio symposium to see what papers and abstracts came out from last year’s conference and send them usually a detailed write-up.

I’ll say, okay let's just remind you we have this stage we have this grade and a new paper came out and the original paper showed this, this, and this, and here’s a graph and a curve. I try to explain it in a way that works for them because I have people who are statisticians and those who don’t understand this stuff at all. I say alright, we are looking at this percent difference, and here is the list of the side effects table so we're looking at a 10% chance of this level of diarrhea or this percent chance of that and at both the positives and negatives and let me know if that helps you make a decision if you want to discuss it further.

Dr. Alschuler:
Yeah, that sounds wonderful. I assume that no matter what they decide, you offer support?

Dr. Bier:
Absolutely. There was a point in my career where I thought I knew what I would do in someone else's position and (laughs) fortunately, I’ve recognized that I have no idea what I would do. I really just want to help people make the best decision. I say to them that the best decision is the one that you are most comfortable with. There is research study showing, and I don’t remember the exact situation - it was abdominal surgery, and I think it was colon cancer or ovarian and they did a scale in advance to see what the level of stress was in the household for that person undergoing surgery. Basically, if they had a higher level of stress, they had more complications from the surgery. We are talking about infections, scarring, and not just that they felt worse afterward. We are talking about measurable complications. So if I can take somebody who has said ‘yes I'm going to go in for that surgery but I'm really not comfortable with it give me information’ and have them say ‘yes I am going in for that surgery I don't like it but boy is it the right decision for me’, I did my job well.

Dr Alschuler:
So many patients don't have the luxury of being able to pick and choose their oncologist. In fact, some patients may have just one general oncologist at their disposal, rather than a specialist in their cancer. As you said, the information is just ballooning in and for that general oncologist to be at the forefront of information in every cancer type is unrealistic. They're getting good solid advice although it may not be the absolute best advice. I'm wondering if there's a way that an average Joe person who is not the doctor, but the patient can be a better advocate for themselves and maybe gain some access to information that they can share with their oncologist. How can you better empower a patient in this conversation ?

Dr. Bier:
That's a hard one. Of course, because if they don't have someone there to help them and guide them, parsing out the information is difficult - it’s difficult for people who have the training! You and I have discussed this - how do you interpret the same study? The information we have available to us is available to anyone these days. Public Medline’s 30 million article all indexed there - that’s available to anybody. In the last five years or so search engines have gotten very good at getting you real information from these journals, and from what was at the latest conferences but of course parsing out the information once you have it is very difficult.

What I try to get people to understand is that when I'm working with them I am there to guide them, but if you want us to maintain clarity on your goals and if your goal is overall survival or extending your survival and hopefully, having a better chance of having your full lifespan is your ultimate goal a realistic one, then remembering that. Using the investment metaphor, if I want to retire rich, if I want to have rich health in my elderly years, I can't get distracted by interim measures. That is probably the best advice I can give people.

I joke with my patients to get your toddler on. Be a toddler and ask ‘why, why, why?’ Be stubborn.
‘My goal is to increase my chance of hitting my natural lifespan and living longer with this cancer.’
‘Well, (they tell me) this immunotherapy works with this mechanism, it’s really wonderful, it’s new.’
‘Great. Does it increase my overall survival or chance of getting my natural lifespan?’
‘Well, this study shows that this reduces tumor markers!’
‘Good, but does this increase my overall survival or my chances of reaching my natural lifespan?’ Be completely stubborn.

What I try to get people to understand is that critical thinking and problem solving - it doesn’t matter if you do it in teaching or plumbing or in mathematics and science - it's the same skillset. The difference is that a plumber has domain knowledge that I don't have and I have domain knowledge they don’t have. My role is to give them domain knowledge. Your oncologist’s role is to give you the domain knowledge, i.e., here’s what this term means and here is why this study shows that yes, we are increasing your lifespan, or no, but…. It’s great to be able to lower your tumor markers. Well, why? Go back to the why. Don't be shy, don't kind of go well this should be obvious and I don't really get it! As I say to my patients, pretend I am the teacher; if you can't explain it to me when you come back you didn’t understand it.

Dr. Alschuler:
Okay, so I want to give you one final question here, which is a doozy. This informed approach that you're talking about in conventional oncology, there's lots of data. Integrated oncology which encompasses, yes, there's research on natural therapies but quite frankly there is not as much clinical research; there is some but sometimes there's none; or there is very little so that the basis on which you're making decisions is really unequal. So how do you manage that conversation?

Dr. Bier:
Well I think it's two parts of it. Number 1 - what we really talked about up till now is just making decisions on your conventional care. We haven't said, and I never say to a patient, “well, you're not going to do this chemo so this is just as effective.” Step one is looking at is the risk benefit balance of this therapy worthwhile to me? And then, when you have a sense of that, turning to the natural side and saying do we have something on the other side that can complement it or replace it in any way.

But to just say, sometimes the best option is no option. That's not comfortable for most people but it's not about does this herb equal tamoxifen? It's about what's the effectiveness of tamoxifen, what's the effectiveness of some of the new immunotherapy and targeted therapies for metastatic breast cancer or colon cancer, and then if that effectiveness is worthwhile to you do you have something that is lower toxicity that may be worthwhile. But the effectiveness is, as you said, sometimes only 2 or 3 percent. And that's within the range of study to study to study so, we don’t need to be able to say because if we are looking at a couple of percentage points that is not much at all. But for that person that might be important to them, and then we can look over and say all right what have we got - what is the effectiveness of this herb, what is the effectiveness of exercise, what is the effectiveness of good sleep, or the effectiveness of this dietary input and then we can compare them. Yes definitely understand that we don't have any comparisons or the results of multi year placebo controlled trials comparing an herb to no herb. So we have to take that into account, be honest about it and yet recognize that it doesn't have the risk and that for some people that may be worthwhile.

Dr. Alschuler:
Excellent answer, and I am sorry we have arrived at the end. Where can listeners learn more about you and about this topic?

Dr. Bier:
Our practice name is Human Nature Natural Health and we are at www.humannaturenaturalhealth.com and my name is not a common one, it’s Dr. Ian Bier, and any search engine will pick me up easily.

Dr. Alschuler:
Dr Bier, thank you so much really appreciate your insight into this and this wraps up this episode of five to thrive live.