Let’s Be Informative…with Dr. Mirhadi
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This is Let's Be Clear with Shannon Doherty.

Hi, everyone. I'm back with a new episode of Let's Be Clear with Shannon Doherty. As I've mentioned before, it's important for me to use this podcast platform to connect with the cancer community in a very personal and honest way. And what better way to do that than to hear from the experts who are caring for me and can speak to this complicated disease with experience and knowledge.

Today, I'm really happy to welcome one of those experts, my friend, Dr. Amin Marhadi from Cedars-Sinai. Welcome. Hey, Shannon. Hi, Doc. Good to see you. Now, I said your last name correctly, right? Yes, you did. Marhadi. Yay! Marhadi Dati. So, can you tell us a little, you're a radiation oncologist. Yes. And I think a lot of people don't necessarily know the difference between, you know, a

a regular oncologist, a radiation oncologist, a cardiologist, oncologist. There's so many different subcategories. Can you explain your specific job? Definitely. So when someone is diagnosed with cancer, I mean, there's obviously the work up to cancer, which would involve like a radiologist, a pathologist, sometimes like a surgeon to do a biopsy. But then when someone has a diagnosis of cancer, there's three main specialties that sort of are involved in the treatment of that.

The main one is a medical oncologist. That's what Dr. Lawrence Piro is. My fave. Love that guy. And he's a wonderful medical oncologist that's taken care of you for many years. And they sort of work as the quarterback. But then another full specialty is radiation oncology. And so I'm involved more on the

treatment side, you know, he's involved more in kind of the management and restaging and ordering the tests and labs and things like that. But my role is the majority of cancers, breast, lung, colon, et cetera, involve some form of radiation therapy, especially when it spreads to the brain or, you know, bones, things like that.

What we do is we are experts in utilizing focused radiation and delivering it properly to tumors and trying to minimize the damage around it. So that's what my role is as a radiation oncologist, which is different than a radiologist who interprets images.

Okay, so you mentioned focused radiation. I met you because I had METs in my brain. I don't remember, was it like five or six? Yeah, well, it was initially six and then three more. And so we did pinpoint radiation on all of those. One of them was surgically removed.

So we can get tissue. We rated that just before Dr. Chu got the tumor out. And we did that mainly to sort of get the tissue and do more analysis and more kind of testing to see if there's anything further we can learn about your tumor. But then we did pinpoint radiation to the rest. And that's a procedure called radiosurgery.

So the reason they call that radiosurgery is because this is delivering all the radiation in one shot. Radiation, when it hits your tissue, if you give a little bit of radiation, it causes a little bit of damage to the DNA of the tumor cells and the tumor cells will then gradually die off.

if you're treating like a large area, you do little bits at a time, like over 25, 30 sessions, which you had, you know, to your chest wall. And that's when you're treating a large area, you have to give the normal tissue a chance to heal itself and fix itself. So you do little bits of radiation at a time when it's a larger areas. But when you're trying to treat like a

distinct tumor, you do all of it at once. You sort of condense that radiation because then you're using radiation to just obliterate everything in its path. So that what you had had to your brain was radiosurgery and that what you had had to your chest wall and then subsequently your rib was what's called fractionated radiation, meaning chopped up into several small fractions. Gotcha. So in my case, I'm hoping that people who are listening saw my Instagram where I posted the video of getting fitted for...

You know, the mask. Yeah. Which I then took home. Was going to wear for Halloween, but I didn't go out for Halloween. Plus, a little scary to put that mask back on. And we did that so that the mask holds, it goes over your head, holds everything in place. You guys lock me in. Yes.

so that there's minimal movement. - It's an amazing process. Well, for you, if you recall, we did a mapping session where we made the mask and then got a quick scan. And then there was like 10 days of doing calculations and planning. When you came back for the treatment, each treatment was like, you know, 10 minutes or so, right? It was quick.

And so patients, they kind of get up and they're like, oh, that's it, right? But they don't realize what's under the hood, so to speak. It's like there is a team of people that, you know, it starts with me, the radiation oncologist. I see you. I determine what I want to treat, how much I want to treat, et cetera. We go through the planning process and we have a team of physicists who all have PhDs in medical physics that are behind the scenes

calibrating the machine, doing calculations. And these are the kind of things that patients don't always see what's going on behind the scene. And this is where where Cedars-Sinai excels because they don't cut any corners on when it comes to like the physics team or the quality of the equipment and doing the quality checks and making sure everything is as precise as it should be. And then the end result is you lying there and getting a tumor zapped and then

going home right you make it sound really easy just lying there just like that but yeah as a as a person who is you know very claustrophobic the mask and you've got this lollipop stick that you know is in your mouth um and the whole thing is to not move because if you do move if you get antsy or if you stop it puts more time onto it and

I did make it a little bit of a competition where I was like, I want to be the one person who moves the least. Yeah. And you, I was like standing there like, Oh, she okay. So someone check her pulse. And also I was wondering where my ice cream went. That's where I ate it and then stuck that popsicle. Yeah. I'll take that. Thank you. Yep. But you know, what's interesting is,

the way we monitor your movement because the machine is delivering radiation. We don't want you to like kind of jerk this way or, you know, we use this optical surface tracking where it's a device that basically

monitors your motion within less than a millimeter. So if you move a little bit, it has this feedback loop to the treatment machine where, you know, it just shuts down instantaneously. So like if you're out of position, we get you back into position before we deliver this very high dose of precise radiation. You know, I mean, you're an actress, right? You get multiple takes. Sometimes we only get one take. Right. Yeah. You guys have to do it perfect the first time.

which is a lot of pressure. It's a lot of pressure. And, you know, you're, again, there's the whole team. It's a huge amount of work that goes into treating literally just one person. And that's what a lot of people don't realize. You know, there are so many people

involved in just delivering that one, just take one of the little tumors we're treating, you know, you just kind of see, you know, like Ty and Marty, like the text at the end. And then like, you know, the, the, the SIM therapist, you see me, and then there's a whole slew of other people. Everyone has to be a hundred percent precise all the time. And then we have to do that day in and day out for hundreds, if not thousands, you know, I've treated over 4,000 women with breast cancer in my career. And like, imagine that kind of pressure, like try to be precise, but

We have so many checks and balances in place. We have such a high quality physics department, things like that. And it's really teamwork at its finest. Yeah. It's one of the things that I really love about Cedars. And that's not to say there aren't other amazing hospitals, but Cedars is

You really understand that everybody who works there, the entire team has been thoroughly checked out, vetted. They follow certain protocols that you're sort of getting the absolute best of the best. And you can go in feeling pretty confident because radiation can be a very scary thing. Oh, yeah. Especially when it's to your brain. Of course. Oh, absolutely. Like I was petrified of radiation.

you know, it's me, not of you. No, you made me feel very confident, but of, you know, is it going to change who I am? Like that, that was, as you know, a big concern of mine, not just with you, but with brain surgery with Dr. Chu of, are you going to,

zap something? Is it going to change who I am? Am I not going to think as quickly? And particularly with the surgery, there was that concern as well. Of course, Dr. Chu ignored me when I asked him to like touch the part of the brain that made me speak eight fluent languages. He ignored me and didn't do it.

But shame on you, Dr. Chu. One thing I asked of you. Yeah, I mean, it is a very scary thing. And you do all sorts of radiation for all sorts of different cancers, correct? Yeah, more or less. Mostly breast and lung, sort of, particularly because those two spread to the brain a lot. I have a question because this is, I've actually been wondering this for myself. Is there a certain amount of times that you can do the pinpoint radiation test?

Like, is there a certain number? And then it's up and then you have to do overall brain radiation? That's a great question.

It's a topic of evolving debate. We live in an era, fortunately, where women with breast cancer in particular are living a lot longer because of all these wonderful therapies. And in the old days, they didn't have that much success. So they would just sort of go crazy with like whole brain radiation and cause a lot of side effects. But the thinking has shifted now to being more pinpoint and precise.

And to answer your question, is there a number like yours? You've had nine total. The answer to that question is how big are they? If you had ten of them that were like 30 millimeters each, it might be difficult.

And yours, fortunately, have all been very small. So we can sort of keep going without causing problems. And I've, you know, in the past, there have been times where I've had to do one that was like close to the other. I ran into some problems, you know, like it would cause some degree of side effects. But

Having many small ones is the best case scenario because then you can sort of keep going and have less side effects, so to speak. So what size becomes not small? Oh, good question.

For single shot radio surgery, when you're delivering all the radiation at once, that's the most intense treatment. That's the most effective, but it also could potentially have the most side effects if you're doing a big area is roughly three centimeters, 30 millimeters. When you get into a 50 centimeter tumor, like I did this morning before I came here, then you have to take that one dose of radiation and chop it out into like, let's say five sessions.

And if it gets even bigger and then you have to include a lot of your normal brain in the treatment field, then it's like up to 30 sessions.

And it's less – when you do 30 sessions, you're delivering more radiation to a larger area, but you're doing it in a way that allows the normal brain to sort of safely regenerate itself. But, you know, not perfectly, but enough so that you can get away with doing that treatment, right? So smaller – the fewer treatments you get, the more effective and the safer. Okay. Let's say –

you know, I had these five or six and then mets and we did however many treatments we did. And then those mets come back and the drugs aren't working and I have to have pinpoint radiation again. And then the same thing happens in three months. I have to come back. And, you know, you just keep on that cycle. As long as they're small, you can just keep doing the... Absolutely. Yeah. And it would be in your particular case,

And this is what something good educationally for people who might be listening. The routine staging, the getting the brain MRI every three, four months, you know, getting the PET CT and catching things relatively early makes all the difference. Because I can't tell you how many times I've had patients who had one or two treated and they're like, oh, let's go to, you know, Barbados or something and just disappear off the grid. They come back two years later and they have one that's like a little bit bigger. Then I have to send them to Dr. Chu and then he

tells them about the language thing and it becomes a whole big mess, you know. He says, no, I'm not going to let you speak multiple languages so easily. But I think it's, but that's the advantage that people in, let's call it Western medicine, when you live in a metropolitan area like LA and have access to wonderful doctors like Dr. Piro and wonderful imaging centers where you can get your scans in a relatively quick fashion, you can stay on top of it.

And that's a thing like patients who are motivated about their health and motivated about, quote unquote, beating cancer, so to speak.

They're the ones that are just, they listen to their doctors. They're on top of things. They do their restaging. They do their blood work when they're supposed to, you know. And sometimes even in cases like that, it might not be enough. But to give yourself and other patients the best fighting chance, you just have to kind of follow the routine, you know. Yeah. I mean, I think what's unfortunate is that

not every insurance company supports scans every three months. You know, like I know that it was tricky for me in the beginning as well. And it becomes easier. This is what's really sad is it becomes a lot easier to get it every three months

the worse you are. So once you enter stage four, they're like, "Oh, okay, yeah, she might need a scan every three months." But you kind of want it before then. Like even every six months is a much healthier way as opposed to the once a year. So few things I'm gonna have to work on in the future advocating for.

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Hi everybody, it's Savannah got 3 from the today show as we head back to work back to school back to everything we want to help you turn your to do list into your today last your morning routine healthy meals and workout plans we've got you covered so you can take it all on with simple solutions to help you through the day everything you need to know before heading out the door so join us every morning on NBC because every day needs today.

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I mean, it is a good thing for us to just remind all of you guys listening to press your doctor too, because if you're feeling anything weird, if you've got headaches and you have cancer or anything, just really, really, you can request. You can say, I think there's something going on and I need an MRI. I need whatever it is, your PET scans. And do go in for your blood test because those

It's amazing how much your blood tells you. Like I didn't even know really how much my blood was telling my doctors about me. You know, sit tight because I would say in the next few years, there's going to be even more tests that analyze your blood and look for circulating tumor cells and circulating tumor DNA and things like that. Genetic testing is going to have a more profound component. We're at sort of an inflection point in cancer care where

we're going to be less reliant on imaging like MRIs and CAT scans and PET scans and more reliant on blood work and genetic testing and molecular testing to understand what direction things are going. The technology is there. Like, you know, there's this one test that was developed out of Cleveland Clinic called the Gallery Test, where it's like a blood test that tells you if your tumor is proliferating or not, you know, and it's relatively in a fledgling state. But

The science is developing. The data is accumulating. We now have artificial intelligence that's helping you analyze this information. And I think we're moving towards a new frontier. You know, everyone likes to say that in cancer care, like everything, every new drug or whatever, it was the new frontier, right? But nothing really has been until now. I think this way to analyze your blood and your DNA and your molecular profile, it's really going to take off in the next few years.

I mean, that's really exciting to hear. And you mentioned Cleveland Clinic, and I just read a whole release from them recently about their clinical trial that's currently happening on breast cancer vaccine. And I found that to be absolutely fascinating that finally there might be a vaccine for breast cancer and that it can apparently work on people who have had it, are in remission, get the vaccine,

And it's possibly, you know, obviously a lot more clinical trial has to be done in order to determine what all it can do. But

I agree with you. It's a very exciting time. And although I always say I can't believe that cancer has been around for, what, 100 years and there's not a cure yet, there's not a vaccine, there's nothing. I'm going to give you my take on what you just said. I know that there's a lot of information online and a lot of people are like, oh, you know, they're trying to withhold the cure. You know, like people think that the industry is trying really not to find it. That

That's actually not true. I think that the person... Oh, I don't think that. No, and I don't think that either. But there is a lot of people who just sort of look superficially online and get some information online

Here is why it's really hard to find a cure for most types of cancers. The reason is because you have a tumor that forms. You know, what is a tumor exactly? It's a portion of your breast, you know, a portion within the duct of your breast developed an abnormality as it was growing. You know, your ducts replenish themselves and they have to go through the process of cell division to make more cells and more ducts and more lobules and things like that.

Somewhere along the way, due to X, Y, and Z factors, no one knows exactly, there was a mutation in the DNA of your tumor cell. Now, the human cell in general is

it's like if you think about it it's it's built to survive that's why humans have made it so long evolutionarily you have a cell that is just constantly dividing growing and growing so you have to think of the human cell as having its foot stuck on the accelerator so it doesn't want to stop growing so every cell in our body inherently could be a cancer cell it just doesn't want to stop growing but we have these big breaks that are sitting on top of it as well i'm oversimplifying of course but when you

When you get a mutation in the big proteins that sit on top of it, the break, so to speak, then cells kind of grow unchecked. But then what happens is, okay, you might find the ability to treat one type of mutation, but tumor cells go through evolution. They evolve. And then you might get a drug like Inherit or, you know, Herceptin or something that might knock out 99.99% of your tumor cells and be an effective therapy.

But it's that 0.001% that might be behind that's resistant to that particular therapy. Then that grows and you have to find a different treatment.

And people can only tolerate certain types of treatment, certain amounts. And so, in my opinion, the best way to address that is catching it as early as possible. Because over time, these cells go through, you know, evolution at a lightning pace and they become resistant. They have this biology where they become resistant to treatment. You know...

Thank you because that's a brilliant way of explaining it in a way that someone like me who does not have a medical degree, although on occasion I like to pretend I do, for me to understand because when you really break it down to how you did, of course, you know, the cell is constantly mutating and growing and changing and becoming something different.

Finding a cure that also can adjust to that mutation is incredibly hard. I mean, I would imagine it's like you could find one thing that would cure it under this particular condition, but then it's already mutated. So then that doesn't even work. It's much like the protocols that we're on, right? So I've actually...

had protocols that have lasted me, I think, a pretty good amount of time for all things considered. But eventually my body stopped it. Maybe the cells mutated, whatever, they changed where that particular pill was no longer impacting it. If I recall, it's been a while since I looked at your chart, but

when you were originally diagnosed you don't look at it every day just to you know i do sometimes i'm just like oh my favorite patient it's not true you guys no i look i look at the tumor i treated i'm like yeah i got it yeah you know um you took care of bob yeah we can start dave bye bye bob bye bye bob um

When you were initially diagnosed, I recall your tumor was estrogen receptor positive and HER2 negative. Now, to the viewers and people who are diagnosed with breast cancer, they hear that and they're like, I mean, there's many layers to what that could mean. In the most simplistic way, estrogen receptor positive means that your particular breast cancer was expressing estrogen receptors, meaning to some degree estrogen was fueling your tumor growth.

Then the HER2, which is a gene that they, you know, that's involved in breast cancer treatment and diagnosis and stuff, yours did not express the HER2 receptor pathway. And then over time in 2018 or 20 or something like that, when your tumor involved

It eventually did. Right. Which suggests that you were able to successfully, Dr. Piro, was to eradicate all of the tumors that you had. There was a little bit left behind that developed its own molecular kind of evolution and its own resistance. And that's what started to grow and that's what came into your brain as we confirmed when Dr. Chu took out that one spot and we looked at it.

Because cancer, and you're a living, breathing example of cancer, how it evolves and how we change our strategy to address it.

So, I mean, yes, by the way, one of my favorite things I probably once a month, I'm going to really sound strange right now, is I look at the picture of my brain opened up that Dr. Chu sent to me. He actually printed it out and gave it to me because he knows I'm like a weird nerd that way. And I

and I look at it and I actually when I got done with brain surgery and I got home I showed it to as many people as I possibly could and some were horrified by it and some enjoyed it like I do but I mean I just think it's to me it's so fascinating that

you know, radiation works the way that it does. And it's, you hear the word radiation, right? And you think of like Chernobyl, you think of like all these crazy things. So you get very, very, very scared of radiation. But because you're doing pinpoint and you with me and with all your patients, you were very careful. You didn't, you didn't laugh at me or sort of ignore the fact that I was concerned about

having more bald spots and patches and that radiation can cause the hair loss. You were equally as concerned, at least in front of me about, listen, I'm going to get every little met that I can and I will do it trying to not

get your hair at the same time like i i hear you i respect the fact that you really want to keep your hair thank you it's a weave uh but it's it's growing underneath this by the way i totally forgot to tell you are going to grow a third ear is that okay i hope that doesn't bother you just just back here can i hear stuff like you know thousands of feet away because i'll take it

You bring up a good, I do want to make a comment about what you just said, because you and I, we had dialogue, of course, I told you about what to expect, what we're doing. One of the big disconnects in healthcare in general, from doctor to patient, just patients trying to navigate the healthcare system, is there's too much information. And one thing that in my 18 years at Cedars-Sinai and my training at UCLA before that, one thing I've

always always made important to me is patients nodding their head at you and sounding like they understand what you're talking about they almost never do and it's really important you know I have I have these you know we just hired like three or four young doctors who are physician scientists and they're absolutely brilliant they are like like one smarter than the next I'm like wow you guys are like you know it's a new era of just like smart people that go into medicine

And, you know, as young doctors in particular, they feel compelled, and this is not right or wrong, this is actually probably more right than anything, to give you all the information. It's almost like a checklist where they have to just kind of explain everything. And what I've noticed is I started out doing that in my career as well until I realized that it became detrimental to a patient. Until, like, the core of what I wanted to convey to them to help them make a decision was,

Was it the very last of a two hour clinic visit where they were poked and prodded by nurses and had an MRI done? It was the last two seconds where I was like, oh, by the way, it might do this and that, you know. And I have been as I've gotten further into my career, I have focused more on simplifying it.

I don't know if you ever saw that movie with Denzel Washington. It was called Philadelphia. He was like a lawyer with Tom Hanks or something. And he goes, he kept saying, explain it to me like I'm a six-year-old or explain it to me like I'm a 10-year-old. And that line always resonated with me because not to try to insult the intelligence of my patients, but I do cancer all day, every day. I know what is going on or what to expect, but you don't or other patients don't. Yeah.

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Hi everybody, it's Savannah Guthrie from the today show as we head back to work back to school back to everything we want to help you turn your to do list into your today last your morning routine healthy meals and workout plans we've got you covered so you can take it all on with simple solutions to help you through the day everything you need to know before heading out the door so join us every morning on NBC because every day needs today.

So join me in the

I think it's also, it's overwhelming. And you go in there and you're already nervous because you are getting poked. You know, you're getting your blood drawn. You're getting an MRI done. You're scared because you have cancer. You're scared because you hear the word radiation or surgery, whatever it is. So then if, if,

If there's so much information coming at you

I think it can drown out your own questions. Absolutely. And I always encourage people to, you know, write down a list of questions beforehand and make sure that they check that list off and to also not be intimidated by the white coat. Yeah. Which is something I find a lot of people are that I speak to. Oh, yeah. That are sick is that they kind of feel they don't have the right to question the doctor. Yeah. Or ask for special things. And.

I'm always like, oh God, I wish you all could go to my doctors, you know, because I've never felt that way. I've always felt like I could push back and that,

I could question, I could say, you know, well, I don't want to get an MRI this month. I want to get them every three months instead. And there's a dialogue about like why that choice is that choice. It takes a lot of experience to get to get to that point as a doctor to value that or to, you know, because you're in your head, you're the expert and you're trying to impart your knowledge.

which comes from a good place, obviously. I very, very rarely meet a doctor who's just out there doing it for kicks or to try to be famous or make money or whatever. Most of them, the vast majority of them really just want you to get better. They want to take care of you. But the approach can certainly fluctuate and it takes a lot of experience. And one thing I like to do is

I like to not overload my patients with unnecessary, too much information that's not necessarily relevant. But I also like to give them my cell phone because what I find is that when they leave my office, there's so much anxiety and there's so much uncertainty. There's so much misinformation out there that sometimes just like a little text message or a little, you know, two second conversation can sort of.

reset them a little bit and take them to a place of like, okay, now I got now that little bit of information clicks to me. You know, when I started out in my career, you know,

I was focused on my career. I got a job at Cedars. I was stoked to work there, stoked to live in L.A. and whatever. And then I remember one day there was one very poignant moment. A woman with breast cancer who had a brain met that I treated. I remember like I did my whole spiel with her. I recommended this, did that, whatever. And then, you know, she went off and I went home. And I always stopped by this Bristol Farms on the way home from Cedars. I was grabbing a tea or whatever. And I saw her there.

with her daughter. I saw her and she didn't see me. And she was just there having a laugh with her daughter. They were picking something and going home to make dinner or something. And at that instant, I was like, okay, my job is about

giving her more days like that, more moments like that. It's about nothing else. It's not about me. It's not about Cedar. It's not about anything other than that woman sitting there is enjoying a day with her daughter, you know, and give her more of those. However you can, whatever. Use your knowledge and expertise in the best way you can to maximize that. And everything else is hot air. I mean, my God, that's such a beautiful way of looking at it. You know, you guys are, yes, you're taking care of us, but you're also...

giving people more time and more precious moments. You know, when we're gone, their children, their loved ones, their friends will be so deeply appreciative that they got that extra moment

that extra laugh, that extra cry, that extra whatever it was. That's very beautiful. You know, I coached just recently, I coached my daughter's junior high volleyball team. I just kind of did it on the side and it was fun. It was great, great experience. There was one thing I kept emphasizing with them. It was a quote that I saw on a Michael Jordan documentary.

It was called The Last Dance, whatever. It was Michael Jordan's 10-part documentary. I saw it. Some guy talked about how Michael Jordan wasn't the best in the world because he dribbled better than anyone or he shot the ball better than anyone or he did whatever, played defense better than anyone. He was the best there was because he was always present.

in the moment. So when I was coaching these young seventh and eighth grade girls, I was like, listen, look around you. Here we are playing a game against whoever. Here you are in the gym. The last time you might be together.

Just be present in the moment because the moment is everything. The moment is what will stick with you. Don't think about what's ahead of you. Don't think about what's behind you. Be present. And that, I think, is what's important to cancer patients, people who are going through it. And I always tell people this. I...

I live my life, you know, as much as I'm capable of, as much as I'm able to to the fullest because I'm surrounded by people like you, by other patients who, you know, they go through something hard. They've gone to the abyss and stared at it, you know, whatever that quote move is from. And they realize that, okay, you know what?

You know, life is limited. It's limited for everyone. But people like you, they realize it more. They embrace it more. And I am fortunate enough to be surrounded by that every single day so that when, you know, my buddy calls me up and says, let's go to Kansas City, you know, for the Chiefs game. Sure. Let's, you know, you take advantage of every moment. You know, someone says, let's have a big 50th birthday party, whatever. Like, go for it. Let's just, you know, go out and have some fun. That sort of thing.

Because that's what life's about. It's that. So let's say for those people out there who are not, you know, as fortunate as I have been to have a doctor like you, who, you know, you cared, you listened, you didn't, you know, think that I was vain for asking about my hair. You talked me through that whole mapping mask process. I mean, you saw me, I was crying, I was hyperventilating.

you talked me through, you were kind enough to shoot video 'cause I asked you to. You basically held my hand through the entire experience and knew how to talk to me and explain things to me, gave me your cell phone number, allowed me to,

you know, infiltrate your private time with your own family after hours to answer questions that popped up in my head, because that happens a lot. You go in, you think that you've got your list of questions, you get overwhelmed, you leave, and then you don't see your doctor again until it's time for radiation or surgery or whatever it is. So the fact that you allow, you know, your patients to text you is, is a, you know, very rare thing, uh, from, from some that I know, but

for those people that don't have a doctor like you in their life, what would be sort of your biggest suggestion when they go in to meet their radiation oncologist? What are the things that they should be asking about? What are the things that they should be looking for? And I know that that answer changes constantly because it's, you know, what kind of a cancer are you dealing with? How big are the mets? Where, you know, is it in your brain? Is it in your lungs? Like,

Is it in your breasts? For you, it's a hard one, but I'm gonna press it. I'm gonna ask it. - So, specifically about women who have breast cancer, any cancer that spreads to the brain,

The most important thing to understand is what's your experience with like the long term effects and the long term outcomes, because sometimes that will vary depending on where the little tumor spots are. Again, this goes back to what I was saying earlier. Sometimes, you know, doctors and health care providers in general, they feel compelled to kind of.

go through that laundry list of like these 20 things that can happen. And that's the part I've noticed scares patients the most. And sometimes it has to be said. Sometimes you have to go through like, you know, when a surgeon says, you might not wake up, you know, I mean, that's happened before. I mean, it's rare. I always like hearing that. Yeah, it's always like, oh, really? Sign here, take a propofol and have a nice, you know. The most important thing to say is how, like some of those laundry list questions is making sure to understand how common or uncommon they are.

and have them really drill down and emphasize what they really expect to happen. Just tell me what you really think is going to happen. And like, let's leave the fluff out and focus in on what I can do to prevent it. Are there things I can do? Maybe there's certain diets or there's certain, you know, preventive measures I can take to limit the swelling that you might cause or what, you know,

things of that nature I think are important is to just be deliberate and to be focused on the most important aspects of your care. Because you have a limited amount of time with your doctor, you have a limited amount of time with the treatment, it's important to be finite, I think. I think that's amazing advice. And then the after the radiation was very interesting for me. You know, the first time I got radiation done for just the

breast wall. Yes, I was like a little tired, but I don't think it impacted me as much. And maybe it's age or maybe it's because it was in the brain. But you were very conscious of saying, listen, you're going to be tired and it doesn't hit you right away. I feel like it built up and the fatigue got much worse later on. That's a great question. And there's a very specific reason for why you get tired after radiation. And it's a good thing.

so when you radiate a particular tissue your body doesn't know how to respond to it so its immune system starts going a little bit crazy like thinking it has a foreign invader so that tiredness is your immune system ramping up to deal with it and that's good in the following sense there's no better you know weapon that you have for fighting your cancer than your own immune system

It's the one that knows what's normal and abnormal in your body. It knows how to interpret that and what radiation does. And frankly, this is part of how radiation is an effective anti-cancer treatment is it ramps up your own immune system. So the radiation causes the same type of tiredness as like when you have a flu, your body is battling off like a virus or a bacteria or something. And it's doing that because your immune system is ramped up. That's why you're tired.

And so that explains why, because you're getting more and more radiation after so many treatments, you just, it keeps growing that fatigue because it's just really fighting all of it. Your immune system keeps going. Which is amazing. And it keeps going for a while.

I think I was also, you know, I mean, I did surgery as well. You had a lot. Radiation and then surgery. You've had the kitchen sink, my dear. I have. I have. I'm almost like a guinea pig. So, but what I also found interesting for my particular case was that we did radiate Bob. For those of you who don't know who Bob is, because we've now, or I've at least mentioned him two or three times, Bob was the bigger,

No.

if it had changed did it become you know was there any her two negative prospects in there like whatever had happened how is it sensitive to certain drugs versus others you know right we have that so we could do a better treatment plan but we radiated bob first and that was i call them seeds it was so that during surgery like there's little cancer seeds that could have spilled out can you explain that so there's two different approaches when you have a brain metastasis or brain met for short

Bob was in a very accessible area. So when Dr. Chu went in there, he made a small incision in your skull and he was able to open the tentorium and just kind of go right to where he needs to and take it out. And sometimes when you're surgically removing a tumor, little tiny tumor cells might just sort of kind of stick to the edges or they might seed along where the incision is.

So that's why we give radiosurgery after the fact. But then the radiosurgery after you remove Bob, you know, it's a little bit more difficult because you don't have a discernible target. You know, sometimes things can shift and things like that. You know, yours was in a place where it could have shifted a little bit. So we thought it was better. Let's just radiate Bob now. And, you know, so that way we kind of sterilize Bob.

Bob's edges. Bob's edges. Sorry, Bob. Listen, you got a name. Bob is on... We sliced and diced Bob. Bob is sitting in paraffin blocks somewhere. We took care of Bob. I asked for Bob. I was like, can you guys please give me Bob? We could give you like a little, like his hand or something like that. No, but then...

that sterilizes the edges. So when we remove it, the edges were sort of dead. So it doesn't seed along the area that we surgically removed. And now we know a year later that, you know, it was successful in eradicating there. So it didn't Bob didn't regrow. But it didn't kill all the Bob.

It was, like you said, just the edges so that when Dr. Chu removed as much of it as he could, it was still alive enough tissue in order to see the pathology. Does that make any sense? Absolutely. Yes. Because the things that we were looking at kind of in a molecular aspect,

would take more than, you know, a few days to change, you know, in the body. So we were able to get enough information to make the necessary changes we needed, you know, to assess, so to speak. You know, if you'd kind of radiated Bob and waited like five or six weeks, there might have been some changes that might have transformed in a way where the information wouldn't have been as useful. But this approach was ultimately the best for you just for that specific reason. So sometimes as an oncologist like Dr. Pirro, you're sort of,

using your best clinical judgment, what responds in what scenario. And that's why I think having gray hair is really important in oncology because you can read the information in a medical journal, you can read the statistics and the outcomes and things like that, other people's experiences. But when you do several thousand of them yourself,

that just gives you a much better perspective of like no when i tried this this worked and that didn't work when i tried that that worked and this didn't work and so experience i think is really important some of your listeners might be hearing this and saying oh my doctor's really young and just came out but they i'm sure have the training and experience of their mentors and people that can help guide them as well you know so

I do think that clinical experience is very valuable in guiding this type of decision making because a lot of it is just to some degree relying on chance and relying on hope that something works, you know? Right. I like my doctors to have some surgical clinical research experience. I want to cover it all. Yeah.

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digging for too much information on everything because there's a lot of chat rooms that are wonderful, right? Where people can support each other, but it can also be a really dark path because somebody will say, oh, well, I have the same thing as you have, you know, stage four cancer. But their body could respond to a medicine that yours doesn't. They could, you know, have

shedding of hair much more than you or much less. So you have to be really careful with those chat rooms and when you're looking for the information yet it's, I think, is it helpful for your patients at least to be somewhat knowledgeable about

- It is helpful for them to be knowledgeable, of course. But sometimes people sort of go down the wormhole and sometimes even if you tell them, no, this is not the case, they still don't believe you because they saw it in some chat room. Here's a good way to think about that.

If you're in a classroom and you lean over to the person next to you and say, hey, I saw so-and-so kissing so-and-so. And then that person turns to the next person and says, I saw so-and-so kissing so-and-so and two other people. And it keeps going around. And just within one classroom, it might come back to you as like, so-and-so was on Dancing with the Stars. Shannon was making out with 50 men. Yeah.

Yeah, I tried to weave in a 90210 reference there. But my point is, in a very short amount of time, misinformation just in a small classroom, small table full of people can just spread like that, you know. And so I always try to tell people like, look, you know, the 4,000 breast cancer patients that I've treated in my career are

Here's my experience. Here's what I tend to see. You know, you might read on the chat room that it causes this or that and that and this. But at the same time, you know, it's a different era. You know, these are women that were probably treated in the 90s or 2000s, you know, different period of time under different circumstances.

So I do my best to try to reel them in, you know, as best as I can. But it is good to be informed. It's not good to let information online consume you and guide you down the wrong path, so to speak. Yeah, I think, you know, I did visit a few chat rooms right in the beginning because I was obviously curious and I found it disruptive for me just because it did feel like a game of telephone games.

But there were other chat rooms that I went into and it felt like a sisterhood and like a family all supporting each other. And I was like, well, that's really beautiful because we all need that. We all need the love and support, especially when you're facing something like cancer. Whatever cancer you have, it's such a difficult disease. But there are some excellent published papers out there.

To give you the kind of knowledge and information that you need in order to go in and feel like you've got a little bit of a handle on your own disease. Because I think that that's the biggest thing is that cancer is still somewhat unknown to the individual who gets it.

that they need to feel armed with knowledge. Yes, absolutely. I'm going to add a little grain of salt to what you said. I've always had a lot of patients and I'd say you're definitely on the higher end of the spectrum in terms of being able to process this information. You're a pretty intelligent young lady and you also, you're getting the right information from the right places. I mean, that's like the top two percentile of knowledge.

of my experience, usually it's like everything in between. Again, the vast majority of patients, they understand the information you're sharing with them. If they bring something up that they learned from the outside, you know, it's easy to just sort of put it into the proper context for them. But not everyone can pull up medical literature papers and recent publications and process it the way you do. And I know you've brought it up with me a couple times in the past. I'm like, oh, wow, that's pretty impressive. You know, I wish they were all like you, but you're the exception, not the rule.

But yes, it's always important to arm yourself with whatever information you can, allow it to be filtered properly. It's usually very helpful if you talk to other people with the same condition that you have. I found those chat rooms to be very helpful because very often sometimes they're in my own patients. They'll make that connection, things like that. But I do think it's incredibly important to find support.

As long as you take with a grain of salt that sometimes the information or the treatment they got might not pertain to their circumstance, you know.

You're very good at that and others aren't. Well, you know, I learned that through, I had Dr. Pirro on and we talked about one of my best friends who passed away from stage four breast cancer, just like me. She didn't have brain mets. Hers had spread to her organs. And when she first got sick,

I really associated everything that she was going through with myself in the beginning. So then when she had all these pains and that meant that it had spread, all of a sudden I got pains and it had spread. Dr. Perra was very...

on top of me about not associating my experience with hers because he said- Night and day. Night and day. Two very different things. Yes, stage four breast cancer. Yours is in your bones. Hers is in her organs. There's two different treatments. There's two different- This is incredibly different. And you cannot associate, even if you have someone who

you find where it did travel into their bones and they have brain mets, it's still going to be different because we're all individuals. And although we can hug and support each other as much as humanly possible, you still have to keep a little bit of disassociation, I guess. And what's worse is that

you know, I'm sure that doctors like Dr. Piro, myself and others, you know, if you're describing a circumstance from another patient to us, unless we treated that patient, you know, we don't know the details. We don't know the molecular basis of their tumor or where it had spread. It's also really hard for us to say, no, that doesn't apply to you because of X, Y, and Z, because we haven't had a chance to read through their chart and say that. So sometimes I see doctors sometimes get frustrated trying to

Kind of tell them it doesn't really apply because they don't have the information to kind of say whether it does or doesn't, you know. Right. And that but that's an important point. And, you know, I've seen a lot of people spiral with with having information from others like that. Yeah. I mean, and it's not just the person with the cancer that spirals. It's everybody else. I I it happened to me very, very, very recently.

where a woman said to me that her dad is a doctor and so she spoke to her father. And how did it feel or how does it feel that I have

Stage four terminal cancer and my time is limited and I was like whoa and she said well my dad explained I'm like oh, yeah to me. It's like first off your dad Doesn't know anything about my particular. Yeah, like broad strokes Sure, just what I've told people and what's out there in the public, but he doesn't know my exact pathology and

And he doesn't know my treatment plan. Like there are so many variables that go into each person's individual cancer that that's why associating your cancer with somebody else's or assuming that you know everything, it's impossible because it just is, it's like the people who tell me, hey, and you know, God bless them because they're just trying to help me. But

You shouldn't be on any of these pharmaceutical drugs. That's what's giving you cancer. Go on a vegan diet or do this. And I'm like, sure. Scorpion venom. That was a good one. Yeah, sure. Let me just, you know, not get infusions and see how fast everything spreads while I try some experimental all natural, which listen, everybody can do what they want individually, but it's a

There's a lot of misinformation about cancer. You bring up a very good point. And it leads me to one of my favorite quotes. I tell my residents and fellows this all the time. There's three types of lies in this world. There's lies, there's damn lies, and there's cancer statistics. The reason I say that, what I mean by that is,

And patients are very focused on this, understandably, of course, but they're very focused on how much longer do I have to live, doc? And I'm like, or what are the chances that I'll be cured? And my favorite answer sometimes is like somewhere between zero and 100% because it's really...

And I think that's where the experience comes in. And I'm sure Dr. Piro feels the same. You know, you see, you've seen it all over the years. You're like, you see someone that thought they were going to be completely cured and hallelujah and go have a big party. And then, you know, two months later, it comes back, you know, crazy fashion. Or you see people where it's quote unquote stage four terminal, all the buzzwords that I think don't really apply in today's era of cancer care.

You see them living many, many, many, many years with no evidence of disease, right? It's really hard to predict what's going to happen on an individual basis. It's really hard to

Try to tell people, hey, you know, I mean, there are some circumstances where the disease might not be responding to X, Y, and Z, and it continues to progress, where you can start to have a sense that, okay, this is not going in a good direction. In the absence of that, in the absence of any discernible progression, just living as a statistic, living as like, oh, I'm terminal, like, you know, it's never –

It doesn't make sense to me. I don't think that's the right way to think about it. I think the right way to think about it, it's highly variable. Do what you can with your doctors and do what they offer you to the best of you can. Be an advocate for yourself as a patient, as you are, and as most of my patients are. Try to learn as much as you can. Learn what your options are. Learn what would happen if it progresses, you know, but

There's no certainty in what this experience is. Right. Which is good because, you know, it gives people hope too. You know, I never, you always want people, even in dire circumstances, you know, you always want people to have some semblance of hope. I saw this quote once. I remember where I saw it, but it was like, when you have health, when you have health,

You have hope. And when you have hope, you have everything. You know, that's really all you need is just a little bit of hope. But, you know, I don't want to, you know, you don't want to mislead people, but you also want to say, look,

A lot of possibilities with what you have, with your condition, with your response to treatment. Hang in there. Keep moving forward. Be present in every moment. Live your life as best as you can. Let us worry about the treatments and stuff like that. And just keep moving forward. Every day is a gift. Every day is a gift. And there are so many new things in the works that I think hope is always there. Absolutely. I think it's so important because...

Listen, I can die today. I could die in 20 years. I don't know. I could die walking outside of my house and a tree falling on me or a bus hitting me or whatever. Or I can die of cancer.

But all I can do is live each day in as much of a positive manner with a lot of hope as I can and embrace it and be like, wow, you know, I get to wake up again today and what do I get to do? And I believe that that positivity that you bring into your life, I think it

with your whole body. I think it helps you fight the cancer because mind over matter. Well, also when you're not as stressed out and anxious, you're not releasing as much cortisol, which can have an effect. And I'm a big believer, you know, not to sound like hokey or anything, but I believe that there is this energy in the world and the universe that manifesting positivity, you know,

can have this ripple effect somewhere in your world, you know, so to speak. But again, it always goes back to what Michael Jordan put, being present in the moment. Like, you don't know what tomorrow is going to bring. You don't know what five days from now is going to bring. All you know is the day in front of you is a gift and you want to enjoy it and maximize it to the best of your ability. Enjoy it as best as you can. And, you know, hopefully there's always hope. You have hope.

Hopefully all the patients who have cancer, stage four cancer, that are listening to this, they have hope too. There's always something that, you know, you can turn over a stone and it might lead to something that might add days, you know, add weeks, years to your life. You just don't know. Right. You just have to keep moving forward.

So we met, if I recall how we met, it was from Dr. Piro. Yes. As we said, he's my general oncologist, I guess I'm going to call it like that. You obviously have to work in tandem with the general oncologist. But

Does that always go smoothly? No, no. Let me like, never. That response was amazing. That was very candid. I'm going to put, uh, I'm going to say something nice about Dr. Piro. And this is why I respect him. I mean, I work with a lot of different oncologists and a lot of them are like, you know, some of them are on the cover of magazine or some of them are like, you know, are big name people that, you know, don't, maybe they don't like to hear other perspectives as much as their own, you know? Um,

Someone like Dr. Pirro, who is a very well-established, very well-respected oncologist, what I've always appreciated about him in particular, you know, is his

He will ask everyone, hey, this is the circumstance. This is the clinical situation. What do you think? He's not like calling me up saying, hey, I want you to do this and that for Shannon or this person or that person. Not at all. Very collegial, very open-minded, very open to discussion. Dr. Giuliano, who I think you know, he's also, he's got this whole- I know, Dr. G. Oh, yeah, Dr. G. He has this army of

you know young surgeons young radiologists young pathologists young just this whole team of people around me he's always trying to learn some every tumor board we have on Thursday he's always trying to learn something new he's always trying to hear your perspective what are you bringing the table what is your experience and it's wonderful to be surrounded by people like that now

They're not always like that. There are definitely some people that are like, nope, this is the way to do it. And you're all right. Like there's definitely egos involved. But I don't see that where I work, fortunately. And I think it's it's lovely when you can all be like, you know, listen, sometimes you might disagree. I'll disagree with colleagues and we'll have playful discussions. But sometimes you're like, you know.

I don't know. You don't know. Let's just sort of do the best, make the best decision that we can for the patient. Do you really tell patients that it's not working? Yes. Very honest with patients. Oh, yeah. This didn't work. We're going to do this now. So how do you approach that? Right to the point. Really? Right to the point. Well...

Ripping the band-aid off. By the way, I'm an advocate of that. No, of course. I'm always going to be empathetic to anyone sitting in front of me that's undergoing cancer care. I'm always going to be sensitive. But

you got to get right to the point, you know, and I do a lot, a lot of my friends, you know, have relatives that call me up and, Hey, what does this mean? Or he told me this or whatever. Sometimes they might not have had the full picture and like, you'll see their report or their image or their MRI and be like, Ooh, that's not good. And you say, okay, this means that, and it's bad. It's not, you know, it's not, it's not something that responds. It's not something that moves in a

good direction and, you know, and you, this, we tried this treatment, it didn't work. So we're going to try something else. And on occasion,

There's not much else we can try that's meaningful. Right. I mean, like that's got to be a much harder conversation is when there isn't something else to try. It is. And I think that in a time like that, when you share that information with the patient, you know, maybe once a week, you know, for me, when you have to say something like that to a patient, there's just like this dark cloak that goes over your head. And that's where me as their providing doctor in that circumstance is.

I have to take a step back, understand they're not absorbing the information from me properly, that I don't want them to make a decision based on something that was so emotionally reactive, something where their life is flashing before their eyes. And that's why I give my cell phone because they'll gather their thoughts a day or two later. I always say to my residents, people I work with,

They're there to see you as an oncologist first. It's always important to get them to a point where they're making decisions that you think are going to ultimately help them or that might give them

a few more days, weeks, months, years. You know what I'm saying? So I think it's important in circumstances like that to always follow up, make sure they're not overwhelmed, make sure they've thought about it, you know, and then say, okay, we can try X, we can try Y, we can try Z. But it's hard. No, no, it's hard. And you do as an oncologist. And I'm a very...

I feel relationships and feel friendships and my patients mean a lot to me on a personal level, but you do have to detach yourself sometimes. Not like in a, I'm not there for you sort of way, but you have to go home and shake it off and prepare for the next day. How do you do that? Because I mean, you know, you have a wife, you have kids, like you have a family and you can't sort of take home that darkness all the time because that would impact everything.

you know, your home life, your family, how do you shake that off? My wife, my wife talks about this all the time. She's like, you know, there's always that first hour or two, like, you know, I might, you know, I might not work till midnight or something, but I might come home at five o'clock and just need like an hour or two to just be like, turn on sports center or go to dinner with a friend or do something and just kind of like decompress. I never, I never take it home and

put it on them, of course, you know, because again, it goes back to what we're saying, you know, life every, every day is a gift, even for me, you know, even though my days are numbered, just like everyone else's, you know, you have to take, you have, you have to make sure you're present in the moment and enjoying every day that you can. But,

And absorbing that and passing it on to other people is not a good, it doesn't help anyone. It especially doesn't help your own patient. You know, they're coming to you for help. They're coming to you to help guide them and you got to be strong. So I always joke that like I'm holding it all in and just one day I'll let it all out, you know, like.

you know run off to antarctica right you know you know be friends with like a polar bear or something and just get a hug this is why i do not um i do not let anyone in in the medical field give me good news or bad news in person because for me it it puts an instant barrier between us where

They can have their own reaction. They don't have to monitor their facial reaction. They can just say it to me on the phone. And then I don't have to monitor my reaction because-

like the first time and second time that it was told to me in person, I felt like I had to A, be really strong in front of everybody and B, help them through it. Not that they were asking me and not that they weren't professional, but I still could see like something a little different in their face. And I had to reassure them that like, oh, I'm not upset by this news. Like not at all. Don't worry about it. I'm,

I'm going to go home. I'm going to have a dance party. Like, and meanwhile, you know, all I want to do is cry and like figure my shit out, but I wouldn't do it in front of someone. Human beings are complicated. It comes out in many different ways.

You have to let people sort of walk their path. You have to let them go through the stages of whatever it is they go through. And you, fortunately, have this wonderful platform. I love that you're doing this in such a way where you're bringing in all your doctors and the people. You're trying to educate people on kind of what the experience, what your experience has been. And you've sort of...

run the table in terms of different kinds of breast cancer therapy. You sort of had it all, you know? And I'm so, I'm very grateful that you sitting here in front of me looking as great you do with things being as controlled as they are. God bless. That's, that's amazing. You know, again, you know, but,

No, not everyone experiences that. And as an oncologist, you just have to do what's best for them. All right. I'm going to wrap this up. I guess, you know, one of those things that people always want to know is like, have you seen miracles? But I think for me, I need to define really quickly in my head what a miracle is. Yes, I'm a highly spiritual human being. I believe in God. So I do believe in miracles. Have you seen miracles?

you know, the worst of the worst, didn't think it was ever going to be better, but something changed. So the answer is absolutely yes. Now, again,

Common things happen commonly, right? And I know everyone wants an answer. They want to know what's going to happen with me. You think sometimes you can guess, but seeing the most dire circumstances switch to a better direction where many months or years or longer than that was added, I have seen. Sometimes there's luck involved. Sometimes there's the human body is sort of this kind of this enigmatic thing and

Sometimes things take a turn that you don't expect as a professional that you haven't seen many times or ever in your past. And again, you have to just always take one day at a time and have hope.

and have faith that you're moving in the right direction and that as long as you do everything you can, when I played football in high school, the coaches always say, leave it all on the field. When you're out there playing, you might win, you might lose. I tell my volleyball girls this too, just leave it all on the court. Don't leave anything behind. You don't want to leave any stone unturned. You don't want to have any regrets about trying this or not doing that. And that applies to life. It applies to your cancer journey.

leave it all out there and then you can just move on in peace. I mean, I agree with that. And I think that, um, I think that's beautiful. I, I kind of look at, you know, I'm on a, I'm not going to say what it, what it is, but I'm on a new, uh, you know, cancer infusion. And, um,

After four treatments, we didn't really see a difference and everybody wanted me to switch. And I just kind of was like, we're going to keep going with this and see. And yeah, after the sixth, seventh treatment, we really saw it breaking down the blood-brain barrier. Do I call that a miracle? Yeah. Yeah.

For me, that happens to be a miracle right now that like I sort of rolled the dice and said, let's keep going. And Dr. Pirro and I, you know, after he looked at the tumor markers, he felt comfortable with that decision. And that it's actually breaking that blood brain barrier is a miracle of that drug and a miracle of, you know, maybe God intervening and being like,

I'm going to give her a break. You know, sometimes you're looking for miracles in all the wrong places and they're right there in front of your face. This is true. Well, I feel like we could easily do a whole nother podcast, a whole nother episode. You're wonderful. I just love you. And for all of you guys listening, remember to go on

Let's be clear pod on Instagram. Send us any questions that you have. And I promise if I have to drive to Cedars with all of my computers and mics and all of that stuff, I'll do it. And, and we'll answer your guys' questions. So thank you. Thank you, Dr. Hardy. Thank you very much.

And I adore you and I really appreciate everything that you do and how fantastic you are with your patience and all of your advice and your expertise. It's deeply appreciated. Thank you for having me, Shannon. All right. Thanks. All right, you guys. Tune in next week to another episode of Let's Be Clear with Shannon Doherty. Bye. Bye.

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