The answer came back: “You can try it if you want, but it’s not likely to make any difference.”

My friend changed the diet anyway. After three months, the counts held steady, without any further increase. Then after another three months, the counts actually went down slightly. There had been no changes in therapy – only the food on the plate.

The rest of the story certainly hasn’t been written for my friend, but this episode represents one of the reasons I’m writing this series; I’m not my friend’s doctor. I have no chart, no protocol, no data set; I’m a friend of thirty years who happens to be a doctor and I was watching – the way you watch when someone you love is sick and you cannot stop reading the numbers.

I’m not trying to say that diet cured the leukemia. I’m just reporting what I was told. One person, one story, is not a study; anyone who hands you a single story, even my story with my own prostate cancer (or even several single stories) as proof of treatment is maybe trying to sell you something. I’m not trying to sell something, I’m just thinking about all this in a different way.

Here is what I AM saying: a reasonable question was asked of the oncologist; the question was closed before it was ever opened. “It probably won’t make any difference” was delivered, not as an invitation to think outside the box, testing a hypothesis, but as a verdict already reached. I found myself thinking at the time, and continue to this day: why did you say that? There’s evidence that diet and nutrition MIGHT make a difference, so what is prompting you to say what you did?

That statement (It won’t make any difference) is the problem I want to talk about. Not the concept that diet and nutrition can be utilized to help treat cancer. The statement made by the oncologist – the fact that our system (based as it is on the premise that no treatment is worthy of discussion unless it has gone through a Randomized Controlled Trial) has no legitimate place to put questions like that, no mechanism to notice it, to track it, or learn from it.

But – there IS such a mechanism. It has a name; it has standing in federal law, and very few people even know about it, let alone talk about it – or give it credence if they do talk about it.

Another Way Forward

It is called “Continuous Quality Improvement”: in this sense, it is an ongoing, observational mechanism for determining what is the right course of treatment for an individual patient, with strict parameters for that observation.

To summarize what I talked about in Parts 1 and 2 of this series (a brief comparison between the Randomized Controlled Trial and Continuous Quality Improvement):

The gold standard for determining treatment protocols in modern medicine is the Randomized Controlled Trial (RCT). This method takes a group patients and they are ‘randomized’ into one of two arms; one arm is given the proposed treatment protocol, and the other arm is given either a placebo or current standard of care protocol based on how the trial is designed. In its finest form, the RCT can correctly identify the best therapy in a given situation, but as Dr. John Ionnidis (now a Professor of Medicine at Stanford) showed, many studies have intrinsic flaws which call the results into question. 12

The RCT was built to answer one specific question: does this treatment, on average, work better than another one, across a population? It is an instrument of generalization; as such, it is designed to find truths that hold for everybody who need that treatment for a particular disease process. That generalization is also a flaw: An RCT, which is slow, expensive, and homogenized — meaning that to be in a trial, the designers set up criteria for patients to be included – if you don’t meet these criteria, you don’t get included. This homogenized group is then set up to provide information to everyone who is proposed to be treated by this regimen, including all those people who may not have met the inclusion criteria in the first place.

The RCT, (which I relied on for my 36 years in practice, as well as when I researched what treatment I would most benefit from in dealing with my prostate cancer 5 years ago), tells you what happened to the average patient in the trial, but not what is happening to the specific person sitting in your office. This method is codified by the government under the Common Rule: Federal Regulation at 45 CFR 46.102.3 Here, research is defined as “a systematic investigation…designed to develop or contribute to generalizable knowledge”.

The other option for research is the longitudinal, observational Continuous Quality Improvement (CQI) method. CQI looks at and tracks the care given to a group of patients in a local setting – and it tracks the results in real time, with feedback loops to change individual care points when change is needed. As noted in my previous essays, this method is recognized by the Federal Government, does not require IRB approval, and can be published in peer-reviewed journals. The notable difference is that unlike the RCT model, which is designed to identify protocols used to treat large groups of patients across the country, the CQI model tracks patients in one location by a treatment team seeking to learn how to improve the quality of care they are providing to a group of patients. By its very nature, the CQI model can (if designed and used properly) truly effect changes in the care of these groups of patients by showing how each patient responds to their individual care points.

The purpose of both methods is different because the aim is different: are you trying to prove a truth for the world, or are you trying to take better care of the patients in front of you?

My friend’s oncologist, standing in that examining room, was operating inside a world that recognizes only the first method (the RCT). “It won’t make any difference” is the thing you say when you believe the only legitimate knowledge is the kind that comes through an RCT. The CQI method, the other method allowed by law, is not normally in the lexicon of the oncologists, hence the very common statement regarding integrative oncologic measures “there is no study” which essentially stifles discussion regarding alternatives in care. It is well-meaning and well-grounded within allopathic dictum, but it misses the opportunity to expand the treatment horizons in a reasonable, controlled (meaning safety features are built into it) method.

THE STANDARD PATTERN

I have now had many conversations with many cancer patients over the last year or two from my new standpoint of Integrative Oncology and the pattern of the conversation which closes the door is the same one: the disease is most often Stage 4. The oncologist, who is being honest (and as kind as possible), delivers two sentences in the same breath. The first one, “We can treat this. We can buy you time, keep you comfortable, but we cannot cure it.” And the second, close on its heels (especially in answer to a question more frequently posed than ever): “Please, don’t go chasing supplements or diets or anything you read online or hear on the internet. It won’t help and it might interfere with what we are trying to do. Besides, there are no studies to show it to be reasonably safe and efficacious.”.

Look and feel what those two sentences, spoken together, actually do to the person hearing them.

The first sentence takes away the hope of cure. Takes. Away. Hope.

The second takes away the hope of doing anything about it at all. Takes. Away. Hope.

The patients are told, in effect: this cancer will take your life, and there is nothing you may do but wait and receive what we give you. So, the question that hangs in the air and most often not asked is: “What am I allowed to hope for?”.

Here is my answer, and it is the answer this entire series of essays has been building toward: I don’t know that these things will cure you. But your question is a reasonable one, and your question deserves better than a wave of the hand. It deserves to be taken seriously, tried carefully, and watched closely. The tools to do that responsibly already exist, but no one I’ve found is using them in oncology.

That answer is embodied in CQI. CQI is the second door to being able to determine efficacy of treatment. More and more patients are questioning whether or not complementary, alternative therapies, repurposed medications and supplements are useful along with, or instead of standard therapies. If we (as treating physicians) pay attention as we are being asked to do by the patients, what does it look like?

I want to start looking at this issue (which will continue in Part 4) by examining some of the aspects of non-traditional therapy. One of the least exotic of these examples is where I want to start.

The Most Boring Radical Idea in Medicine

If I told you I wanted to give a cancer patient a drug that is cheap, has been taken safely by hundreds of millions of people for decades, and costs about $4.00/month, you might be just a little curious (I hope).

The drug I’m looking at first is all of those things and it is Metformin. It’s a first line drug for treating Type 2 Diabetes, has been used since the 1950s, and is on the World Health Organization’s list of essential medicines; in many insurance plans, it has no copay; even without insurance it is less than $10/month. Alongside it is Berberine, a plant compound used in traditional medicine for centuries which performs in similar fashion to Metformin, is easily available today as a supplement, and has a growing file of clinical evidence behind it.

Neither of these is a fringe substance; neither is considered dangerous during normal use, and both have a striking property that has nothing to do with the conditions they are usually used for:

They interfere with the way cancer cells feed themselves. 45

I plan to go a bit further into the biology and other specifics in Part 4, but for now, I just want to get the idea on the table. The idea that substances other than standard chemotherapy may be useful and effective in treating cancer (I’m not saying AS effective or suggesting that they can be used INSTEAD OF chemotherapy).

Many cancers have an unusual variation of metabolism that I never learned in medical school (I haven’t spoken with many doctors who can remember it being taught either): it’s called the Warburg metabolism after Dr. Otto Warburg, a German physiologist, who’s experiments in the 1920s won him the 1931 Nobel prize in Physiology6. Basically, what he showed was that cancer cells use glucose (sugar) as a primary source of energy by a less complicated and less efficient mechanism to produce energy than our cells normally use, but which cancer cells are very efficient at using.

Metformin and Berberine both – by different routes – interfere with that metabolic machinery cancer cells use to feed themselves. The theory that they MIGHT slow the growth of certain cancers is not just theory; there is real cell biology that is known and shows the possibility. And there is real human evidence pointing in interesting directions – not proof, but, as you know – “there are no studies”.

In the normal world of oncology, if a patient with Stage 4 cancer asks the Oncologist “What if I take Metformin? Could I try Berberine?”7 8The answer is reflexive and predictable: “There’s no study, no Randomized Controlled Trial proving it works for your cancer, so no, don’t bother.” Or – “There’s no study, so you can if you want, but it’s not likely to matter.”.

The question dies right there; the same place the hope dies.

Under CQI, the answer is completely different. It isn’t “yes, this will cure you” (that is indeed not proven and would be an unfair answer). The answer is: “Let’s find out!” We can check and make sure Metformin and/or Berberine won’t interfere with your chemotherapy, or how your body processes other drugs you might be taking (because they can do either). This interference is exactly the thing the oncologists are (correctly) concerned about and the possibility of and a plan to avoid such interference needs to be properly evaluated by someone who is interested in doing so. We establish your baseline – your labs, your markers, how you feel. We add the agent. And then we watch. We measure. We track what happens, month over month, and we adjust. We do the thing the oncologist told my friend was pointless: we pay disciplined attention to what actually happens in one real human being in real time.

The Real Difference

That prescription does not require the mechanisms of a Randomized Controlled Trial; we are not trying to prove Metformin cures cancer for the world. We are trying to take better care of the patient in the room with us; it is the definition of quality improvement I talked about in the beginning. It is legal; it is legitimate; It is, in fact, exactly what that federal regulation carves out room for. And done across many patients, with many other substances – carefully, with honest observations and adjustments – not instead of the RCT, but in the wide-open space the RCT was never built to reach. And for late-stage cancer patients, it opens the door to allow hope to enter the equation.

Before heading to Part 4, I want to acknowledge a couple of things: one is that just as it’s wrong to offer NO hope to someone with cancer, I truly believe it is even more wrong to offer false hope of a cure in that situation. The other one is that Integrative Oncology is an interesting field; in some ways, it is indeed the Wild West; there are many different theories about treatment and how to deal with all the possible options (without — ahem — studies). In other ways, it is more human and humane than allopathic medicine understands it to be.

Cancer is a complex beast. The death rates from cancer have decreased in some cases over the last 20 year as early detection and newer therapies have made a dent in survival time, but the very word still raises fear in the human soul, and it remains as a threat from the moment of diagnosis.

What if we were able to show improvement (via CQI) with the two systems working alongside each other? If Metformin and Berberine (as well as literally dozens of other medications and supplements) cause no harm (or the harm is easily mitigated by knowledge and observation), then WHY NOT try?

CQI is built for this time.9

“Come, let us reason together.”

Isaiah 1:18

In Part 1, I reviewed some of the history surrounding the concept of Randomized Controlled Trials (RCT) as the current basis for medical research; current medical therapies are most often based on the findings from these RCTs. For those interested in a deeper dive into that part of research, I highly recommend the Substack recently written by Dr. Paul Marik. He clearly sets forward the concepts as well as the faults of those concepts. In this essay, I want to approach an alternative pathway to finding a way forward for medical research: Continuous Quality Improvement (CQI) as a mechanism for the Longitudinal Studies Dr. Marik references.

CQI is not an alternative to evidence. It is an alternative to a particular evidentiary apparatus (Randomized Controlled Trials). TheRandomized Controlled Trial has been, especially in oncology, treated as though it were the only legitimate kind of evidence. The question of regulatory grounding needs to be answered, as the Institutional Review Board (IRB) process is one of the major governing precepts of the RCT methods in standard use. In other words, a proposed human study in the RCT format requires IRB approval; this approval itself can add months or longer to the whole process.

Quality improvement activities have been distinguished from human subjects research, and exempted from IRB review, under U.S. federal regulations since at least the implementation of HIPAA in 1996. The HHS Office for Human Research Protections has issued explicit guidance on this distinction.1 Quality improvement that focuses on local process improvement, uses real-world clinical data, and is interpreted by the care team to improve care delivery is categorically different from research designed to produce generalizable knowledge through controlled experimentation. The 21^st Century Cures Act,2 signed into law in 2016, further opened the regulatory pathway for the use of real-world evidence in FDA review processes. CQI is therefore, NOT a workaround. It is a mature, legally recognized, scientifically defensible evaluative apparatus.

To summarize those thoughts: CQI is a valid method for approaching changes in care in a local setting and has been given validity in that arena.

What I am proposing is not that we replace the randomized controlled trial. I am proposing that we deploy the trial and CQI for the questions each is best suited to answer – and that we stop treating the trial as the only legitimate tool when, for many of the questions our patients actually live inside of, it isn’t.

The Sub-optimization Problem

One of Dr. Bruce Ramshaw’s (see Part 1) sharpest contributions to this discussion is the concept of sub-optimization: the improvement of a subprocess in ways that do not improve, and may actively worsen, the outcome of the whole process.

His example outside oncology is sepsis. The implementation of standardized hospital sepsis bundles has reduced in-hospital sepsis mortality, an outcome hospitals report and that regulators reward. But long-term outcomes for sepsis survivors – cognitive impairment, persistent weakness, readmission, and late mortality – have not improved, and in some cohorts, have worsened. The subprocess metric got better. The whole process got worse. Why? Unless multiple factors are tracked, rather than just the one outcome, then the generalization of the process ultimately is less successful.

Oncology, I think, is structurally vulnerable to the same problem. We have subdivided the discipline into modalities, each with its own protocols, its own quality measures, its own optimization targets.

Surgical oncology measures margins and complication rates.

Medical oncology measures response rates, progression-free survival, dose intensity.

Radiation oncology measures field accuracy and toxicity.

Each modality optimize within its boundaries. None of us, individually, owns the patient’s whole trajectory through the treatment cycle.

The spaces between the modalities:

Diagnosis to first treatment; Surgery to chemotherapy; chemotherapy to radiation therapy; delay in continuing chemotherapy due to toxicity; the end of active treatment through survivorship, are the spaces no specialty has been organized to manage. Some of this work falls, sometimes, to palliative care or psychosocial oncology or nutrition services, exercise physiology services, usually on referral. But many times, the referral is after problems have already developed.

These ‘interstitial’ spaces are also, not coincidentally, where the patient’s whole experience of the illness mostly lives.

This is the space I am proposing we at least begin to work in together. A CQI framework anchored on the whole patient care process, defined, for example, as “newly diagnosed Stage II breast cancer through completion of adjuvant therapy”, does not compete with the modality-specific work any of us is doing. It does work the modalities are not currently organized to do.

The Lifestyle Bucket

I want to spend some time on what kind of interventions go in the interstitial spaces, because I know this is where the beginning of change can occur. This first set of interventions (in addition to standard care), are mostly what are fairly called supportive and lifestyle care: structured nutritional support as seen from an integrative context (diet IS important and has scientific underpinning); exercise programming has Level 1 evidence in multiple cancers now; cognitive-behavioral therapy for treatment-related anxiety and depression; sleep restoration; structured patient navigation; mindfulness-based interventions for distress, community, and spiritual support for patients who want it.

NONE OF THIS IS FRINGE.

Most, if not all, Oncology centers are already using one, or many, of these modalities to help their patients.

What I am proposing is that we do it more systematically, in the context of a defined patient process, and that we measure what happens when we do.

The Elephant in the Room

Repurposed drugs and supplements are also part of the larger conversation, and I want to explicitly bring that point into focus. Many patients (if not most) are already reading about things such as Ivermectin or Vitamin D to name two of the most familiar. There is a wealth of information on these medications, some really good, scientifically based (though mainly pre-clinical), and some wildly outlandish without anything but a hope and a prayer.

Traditional oncology has seemingly dismissed all these options without a second thought. The problem lies in the tension between what the patients are reading (or experiencing) and what the Oncologists believe – based on the RCT model. And that tension is gradually rising on both parts. The patients on one side are already taking supplements and/or asking the oncologist about said supplements. Meanwhile, the oncologists on the other side are either blatantly saying NO to all supplements or denigrating the concept of supplements to the point patients feel ashamed to have even brought it up.

I want to address this issue directly from the CQI perspective because of the value that these things can (and have brought – albeit ‘anecdotally’) to the quality of patient’s lives as well as the value they can potentially bring to the overall success of treating cancer. That will be in Part 3 of this series.

The Asymmetry of Risk

One of the deepest reasons oncology resists evidentiary frameworks other than the RCT is that oncologic therapies are toxic within narrow windows. Targeted agents have unpredictable off-target effects. Immunotherapy can produce life-threatening immune-related events. When the cost of getting it wrong is severe, the demand for trial-grade evidence before deployment is not only appropriate, it is essential.

This logic does not extend, however, to all interventions equally.

Consider the kinds of interventions that go in the interstitial spaces. Structured exercise programming during chemotherapy. Nutritional optimization in the weeks before surgery. CBT for treatment-related anxiety. Sleep restoration. Mindfulness-based stress reduction. Patient navigation. The risk profile of these interventions is not the risk profile of cisplatin. The therapeutic window is wide and the mechanisms of harm are limited and well-characterized.

When the intervention is high-risk, the cost of acting without trial-grade evidence is high, and basing treatment on the trial is not unreasonable at all. Conversely, when the intervention is low-risk, the cost of acting without trial-grade evidence is low.

The cost of not acting, of failing to support the patient through all the interstitial spaces while waiting for trials that will take a decade – and may never be funded – is itself a clinical choice with consequences. CQI is built precisely for this case. It does not exempt the interventions from rigor. It applies a rigor proportional to the risk and embedded in a framework that can learn from real patients in real time.

The Hard Questions

There are objections to this approach that can be raised, and the objections deserve real answers rather than rhetorical dodges.

Where is the evidence in Oncology? Ramshaw and colleagues have published on CQI applications in hernia surgery, including the elimination of post-reconstruction drains and the identification of patient emotional and cognitive complexity as a high-signal predictor of chronic post-inguinal pain – a finding that led to the integration of Cognitive Behavioral Training as preoperative optimization, with measurable improvements in outcomes. The cancer applications largely remain to be built.

That is the work I am proposing.

The supposition is that we will build the evidence by doing the work, in a framework that is designed to learn from doing the work.

What about patients drawn away from evidence-based treatment by integrative claims? The CQI framework operating inside a defined oncology care process likely produces the opposite effect: drawn within the framework of the Oncology centers (which again, are doing a lot of these things already), the support becomes truly codified within the boundaries of CQI, and more importantly, the support can become measurable.

What about the reputational issue with ‘integrative medicine”? Coming from my life as a purely allopathic doctor, I’m well aware that the concept (whether named integrative or complementary or alternative) carries baggage and is looked down upon. What I am proposing here is a continuous quality improvement framework, embedded in an existing care process, evaluated against measurable outcomes that we, as a team, define as significant to the care of patients.

What This Looks Like in Practice

Imaging a CQI framework anchored on a single defined process: a patient with Stage II breast cancer, from the date of biopsy diagnosis through completion of adjuvant therapy.

The first decision is the team: A medical, radiation, and surgical oncologist (sometimes one, sometimes all); a Patient Navigator; , an oncology-trained nutritionist; on oncology-trained exercise specialist; and the patient (plus a supportive family member or friend). A small care group wherein each member sees a different piece of the whole. Together they form the Circle of Care which provides the parameters and oversight of Continuous Quality Improvement. This figure represents (as Bruce Ramshaw introduced to a small group of us 15 years ago) true Patient Centered Care: a patient surrounded by a care team invested in taking care of that patient in concert, with specific jobs and specific goals:

The second decision is: what to measure. Not everything that is part of the cycle of care is measurable, and not everything needs to be included – that is the sub-optimization trap in reverse. The team identifies outcomes that matter for this defined process:

Treatment completion rates

Dose reductions and delays in treatment

Hospitalizations during treatment

Symptom burden across cycles

Functional status at defined intervals

Quality of life at defined intervals

Depression and anxiety screens

Weight and metabolic markers across treatment

Return to baseline activity

Recurrence-free survival and treatment-related late effects

Some of these we already collect and report on, albeit not consistently within a framework. The CQI framework collects them deliberately, in defined context, in longitudinal fashion. And please note: I don’t at all pretend this is the exact list; the list for these observational studies should be made by the team as a whole without a physician micro-managing the list.

The third decision is: what to do with the data. Weighted correlation analysis across factors and factor combinations, rather than significance testing of single variables. Visualization tools that let the team drill into the data rather than receive static dashboards. Here’s a key factor: Feedback Loops; performed at defined intervals so that what is learned in one cohort informs the next and the next…all building upon the experience over time. The introduction of specific interventions in the interstitial spaces, all of which are then evaluated against the outcome measures, in context, with the explicit goal of improving them:

Prehabilitation between diagnosis and surgery (there are MANY things that can be done, routinely, to improve how well a patient tolerates surgery)

Structured nutritional and exercise support during chemotherapy and/or radiation therapy

Behavioral and faith-based support for treatment-related distress for patients who want it

Over time, the framework accumulates institutional knowledge that no single trial could produce:

Which interventions help which subpopulations

Which combinations or factors predict which trajectories

Where the high-leverage points in the process actually are

Please note: None of this replaces the trial-based evidence that determines which chemotherapy regimen to use.

All of these CQI processes operate in the territory the trial-based evidence was never designed to address.

To all my medical colleagues:

What I’m talking about in this essay and what I am asking to happen is NOT for any of us to do less of what we are already doing. I am suggesting there might just be a framework we can build together that can not only address the interstitial spaces between and around treatments, but during the entire cycle of care of patients who have a cancer diagnosis. We have not been routinely organized around this concept. The framework of CQI/longitudinal studies already exists, in the work that Dr. Bruce Ramshaw, as well as others have produced.

The patients we treat deserve to have it brought to them. If we cannot learn (or seek to learn) from this suggested framework, then we are likely to be leaving most of what happens to our patients outside the reach of what we call evidence.

To the lay folk reading this essay (most of whom are already familiar with the patient side one way or another): Contemplate these thoughts; if they resonate, bring them to your local situation.

I’ll leave you with one of my favorite quotes:

NEVER DOUBT THAT A SMALL GROUP OF THOUGHTFUL, COMMITTED CITIZENS CAN CHANGE THE WORLD; INDEED, IT IS THE ONLY THING THAT EVER HAS.”

Margaret Mead

I’d like to believe that we could be that group. And I cannot wait to find out!

Part 3 will address further the vision that CQI may be a way forward together to help redefine patient care.

A few weeks ago, I wrote Part One of a thought process regarding medical research, called “The Spaces Between”. I have been working on Part 2 (now expanding to Parts 3A and 3B) and am going to post them soon. The more I have thought about this subject matter and the more I have written and re-written these articles, the more I believe the subject is not only an important one, but one which deserves a wide audience. An audience that is capable of having the discussions needed to hopefully effect a change in how we approach ‘evidence’ as a mechanism for determining what therapy or therapies are the right ones for an individual patient.

If you have read my first few essays here, you know that I was a General Surgeon for 36 years before retiring in January of this year. I retired not because I wanted to give up surgery as a career (I still miss being in the OR), but because I felt a forceful push in my life to pursue this new career. Whether you call it Integrative Health, Functional Medicine, Lifestyle Medicine, Holistic or Naturopathic Medicine — it is the area I have been drawn to with such conviction that I had to retire. Once I learned how to reverse my own Type 2 Diabetes, once I saw what medicine was becoming (in all the wrong ways) during Covid, and once I learned how to help myself use my own growing understanding of how to get healthy to fight prostate cancer, I could not turn my back on it.

In my surgical office, I found myself talking more to patients about their health than I did about their surgery. Over the last 2-3 years of my practice, I was able to help several people either decrease their medications or to get off some of them entirely. I dove into learning basic physiology more than I had at any time since the first year of medical school.

I’ve learned things about physiology that I was never taught (or at least taught purposefully and clearly) in medical school. I had never (to my recollection) heard about the Warburg metabolism which is now so very central to the understanding of the Metabolic Theory of Cancer (which wasn’t a thing back then). The fact that Otto Warburg (a German physiologist) won not one, but TWO Nobel prizes for this work without any mention of it in medical training still amazes me.

I was taught about cell structure and function; about cell division; about the function of organelles, such as mitochondria as well as about oxygen free radicals. But it was not in the context of how damaging these reactive oxygen species (as they are now called) are to the function of mitochondria—the powerhouses of the cells. And pulling it all together, I was not taught that this damage to mitochondrial function is the root cause of most, if not all chronic diseases (diabetes, hypertension, chronic arthritis, and yes, even cancer). I certainly was not taught that this damage CAN BE REVERSED! In fairness, all of the theories were not fleshed out in 1984 when I graduated from the University of Florida College of Medicine, but there was certainly a better understanding of them in other fields and the concepts were by all measure, not unknown.

I’m going to use a very overused phrase, but it so totally describes how I came to leave allopathic medicine that I have to say it: Once I saw it, I could not unsee it. And there is SO much more information than the above paragraph intimates. It has caused a seismic shift in the way I view medicine in general and my place in it in particular.

At first, I was drawn to the prospect of helping people reverse their chronic diseases by engaging them 1) to understand the disease process on the cellular level, 2) to understand that only THEY can truly effect change in their bodies by what they eat, how they exercise, how they sleep, and yes, even how they pray, and 3) to challenge and support them and to help them make those changes.

It is amazingly more challenging but also amazingly more rewarding to teach people these things than it is to just write a prescription for medications which treat the symptoms of those diseases, but do not in the least begin to truly treat the disease process. The problem is that allopathic medicine has taught patients to be like fast food consumers: it’s easier for patients to take a pill than it is to go home, clean out the pantry and learn how to cook and eat healthy. It’s much easier to go to McDonalds than it is to cook your own meal. It’s much easier to not get up and exercise.

Finally, after over 45 years of medical school, surgical residency, and then surgical practice, I had found a new place in medicine.

As I began to figure out how to practice this ‘new medicine’ I had to learn how to start doing it online and started my own business: Sunrise Institute. Over the last few months I have been inexorably drawn toward Integrative Oncology, which is anathema to my oncologic colleagues in many cases. I have to point back to my learning process of how do deal with my own prostate cancer as the beginning; also to reading the first edition of Dr. Marik’s book “Cancer Care - the role of Repurposed Drugs and Metabolic Interventions in Treating Cancer” which opened my eyes to this new world. I have since found kindred spirits all over this country (and the world), and have become totally engaged in treating this dread disease. During my career I operated on several thousand patients with cancers of various kinds. Now the treatment is different but no less rewarding.

Integrative Oncology can mean many things to many people. Viewed from above, it can be scattered in its thinking, in its performance, and even its purpose. Allopathic medicine views it with a jaundiced eye because in many ways it is not truly organized around what would normally be considered ‘science’. Also because it has so many different mechanisms of practice by such a wide variety of individuals with different scientific backgrounds. That jaundiced view is not unfair in many cases, but it also completely ignores the amazing things happening which are prolonging, if not outright saving lives. The problem is that none of us knows what things or combination of things really works in any given individual to make a positive impact.

The fact we don’t know what actually works gives the high ground to traditional oncology because the treatments therein are prescribed by the holy grail of determining safe and effective protocols: the Randomized Controlled Trial.

But — what if we could learn more about ALL the various treatments by applying them differently than we do now — based on Continuous Quality Improvement (CQI) rather than the RCT. I’m asking that question myself now because of my experiences over the last few months of helping to take care of patients with cancers in the face of a persistent resistance on the part of oncologists to even allow any kind of supplements to be used while they are treating patients with chemotherapy or hormone therapy. This prohibition is absolutely correct when viewed at one level because different supplements actually can and do interfere with standard chemotherapy if used inappropriately.

However, more and more patients are taking these things anyway, without any supervision, and many times without the knowledge of their oncologist.

What if we had a way of doing both?

What if we had a way of studying what we are doing in real time?

What if some of these natural things actually improve the efficacy of standard therapy?

What if the ‘preclinical’ status of the mechanistic understanding of safe substances like Curcumin and Doxycycline could be safely and judiciously placed into the clinical arena?

What if Hyperbaric Oxygen Treatments or High Dose IV Vitamin C really CAN positively effect the destruction of resistant cancers?

What if we could potentially standardize and not demonize Integrative Care?

I BELIEVE WE CAN.

It starts with building a framework utilizing the precepts of CQI which more adequately deal with and help resolve Complex Systems. Cancer IS a complex system, different in every individual.

I learned about CQI from Dr. Bruce Ramshaw who has been brilliant in bringing the concepts to clinical medicine. You can find him on LinkedIn.

RCTs don’t begin to describe the complexity and CQI in longitudinal, observational studies can potentially help show the way forward.

I don’t at all believe that I have all the answers. Collectively, I believe we can find them.

Part Two of the Spaces Between will be up on Tuesday.

For new readers: I was diagnosed with high-grade prostate cancer in 2021, underwent radical prostatectomy, did well, but 18 months later had a recurrence in four lymph nodes in my pelvis, followed by 6 months of Androgen Deprivation Therapy. About the time of that treatment, I learned about lifestyle changes (diet, nutrition, exercise, sleep, stress reduction, prayer/mindfulness/meditation) which can make a significant impact on cancer survivorship. I also learned of other, natural substances which have been shown in animal studies and/or labs to have anti-cancer capabilities by blocking certain growth pathways.

As of now, 33 months after my last treatment, I am still free of cancer.

I’m not claiming to have been cured, but with only the natural components mentioned above since September of 2023, I have done well to this point.

Truthfully, I am not at all saying that my path would have the same response in anyone who has a diagnosis of cancer. My story isn’t proof of anything. I am an n=1, an anecdote — and I recognize that fact. I truly don’t know whether the lasting remission is from the ADT, from the supplements, from the lifestyle changes, from divine intervention (I am a Christian, and I do pray about this), or from the simple good luck that all of us dealing with cancer as doctors have seen wherein patients survive when we thought they wouldn’t.

What I CAN tell you is that I am the kind of patient the current evidence framework which defines research (randomized controlled trials) is unequipped to learn from. That inability to learn from cases like mine — and what possibly can be done to correct that blind spot — is the purpose of this essay.

I am going to break it into two parts because there is a lot of information to unpack and I genuinely feel it is too important to the future of medical care to compact it too much.

The Wartime Roots of How We Decide What Counts as Evidence

In November of 1944, with the Allies advancing across France, President Roosevelt sent a letter to Vannevar Bush, the director of the Office of Scientific Research and Development. The country was about to win a war it had won in part through the systematic application of science to problems of immense complexity — radar, the Manhattan Project, penicillin produced at industrial scale, the design and manufacture of tens of thousands of complex war machines in less than three years. Roosevelt wanted to know whether the same approach could be turned, in peacetime, to the war on disease. Bush’s response, Science, The Endless Frontier,1 became the founding document of postwar American science policy and gave us what historians call the “linear model of innovation”: basic research feeds applied research, applied research feeds clinical practice, clinical practice feeds outcomes.

The prospective randomized controlled trial, already emerging as a methodology in the late 1940s, became the engine of that linear model in medicine.

I want to be careful here, because what follows is going to read like a critique — and I am NOT saying the framework should be tossed out. Far from it. I am a trained allopathic physician and have lived in that linear world since I graduated from medical school in 1984. I practiced in it as a surgeon for 36 years.

What this approach achieved is one of the great public health achievements of the twentieth century. The 1954 Salk field trial — at the time, the largest medical experiment in history, with nearly two million children enrolled — established the efficacy of the polio vaccine and changed childhood in America. The combination chemotherapy regimens worked out in the 1950s and 60s turned childhood leukemia from a near-universal death sentence into a disease that is curable in the great majority of cases. The targeted therapies and immunotherapies that have, in our own time, extended the lives of patients with HER2-positive breast cancer, chronic myeloid leukemia, melanoma, and a dozen other malignancies — all of them owe their place in our hands to the same evidentiary apparatus. No one who treats cancer patients would willingly give it up. Giving up processes that are efficacious is not what this essay is about.

But the framework was designed for a specific kind of question: does this discrete intervention, applied to a defined population, produce a measurable change in a defined endpoint? Where that question is the right question, the RCT model is unmatched.

The trouble begins when we extend the same framework to questions it was not designed to answer — and then conclude that any question it cannot answer is not a real question.

What the Trial Cannot See

In this discussion, I am leaning on the broad academic shoulders of Dr. Bruce Ramshaw. I first met Bruce in 2008 as he was being sought to serve as the academic resource for a new surgical residency program. He was well into his research of how hernia meshes can have such varied effects in different people, which eventually evolved into a deeper study and understanding of medical issues through the lens of complex systems science rather than seeing them as linear problems answerable by the RCT methodology. In a chapter from the SAGES Manual on Surgical Quality2, he enumerates the structural limits of the randomized controlled trial with particular precision. I want to summarize the ones I think matter most for what I believe needs to be brought into the discussion of cancer treatment.

The trial assumes that variables can be controlled. In a real patient, in a real clinical environment, the variables cannot be controlled. A change in any single variable — the patient’s gut microbiome, his/her stress level, the timing of meals relative to taking medications, the stressors of an individual life, the overall health status before treatment which defines the immune system’s capabilities of overcoming the disease or the treatment of the disease. Indeed, even the nuances in the strands of DNA which provide the differences for each one of the more than 8 billion inhabitants of this planet.

All of those factors can shift the outcome despite identical intervention.

The trial’s apparent precision is purchased by an artificial reduction in the world it studies. We accept that price (often appropriately) for the benefit of internal validity.

We sometimes forget what we paid.

The trial assumes generalizability. A result obtained in a tightly defined study population is presumed to extend to all comers. Sometimes it does; sometimes it does not. Dr. Ramshaw points to a 2019 analysis in Science3 showing that a widely used population health algorithm produced significant harm to African American patients precisely because the data it was trained on did not generalize. We have all seen versions of this outcome — patients who don’t look like the trial population getting the trial’s treatment, and getting the trial’s expected outcomes only sometimes.

The trial assumes that nothing changes. Static treatment guidelines, generated from trials completed three, five, or even ten years ago, do not necessarily accumulate new information as biology evolves and as practice shifts. Without feedback loops, any protocol can degrade over time. Dr. Ramshaw also reminds us that the American Statistical Association issued a formal statement in 2016 about the widespread misuse of p-values and significance testing in clinical research.4

Most of us were not trained in medical school, residency, or in practice to question the premise of studies from this angle. I certainly include myself in that statement as I practiced for all those years within that framework.

The trial isolates a single intervention from the whole patient process in which the patient actually lives. It produces a clean answer to a clean question, in a world that is neither clean nor simple.

It is not a flaw in execution of the study. It is a feature of the model.

The model has limits, and the limits are not failures of rigor; they are the unavoidable consequence of the kind of rigor the model imposes.

Cancer as a Complex Adaptive System

Cancer is, I think most of us would agree, the paradigm case of a complex adaptive system. The tumor itself is not a static lesion; it is a population of cells with internal genetic heterogeneity (in other words, cancer cells biopsied from different areas of a solid tumor can have different appearances and effects).

Tumor cells evolve under selection pressure from the immune system, the local microenvironment, and any therapeutic agent we introduce. Tumor cell plasticity refers to this evolution of tumor cells in response to various pressures.

The patient is not a passive substrate; he or she is a coupled system of metabolism, microbiome, neuroendocrine activity, sleep architecture, immune function, and psychological state. Each of these stated factors (plus many others) influences how an individual responds to the presence of a tumor as well as that individual’s response to treatment. And treatment, of course, perturbs each of the factors slightly differently in each individual.

I do not have a reductionist account of why two of my patients with identical staging, identical molecular profiles, and identical treatment regimens have radically different outcomes. None of us does.

We chalk it up to biology, to variation, to luck, to genetics we haven’t yet mapped. What complex systems science says is that the outcome is the emergent product of a vast number of interacting factors, only some of which any given trial chose to measure. In Dr. Ramshaw’s framework, the same intervention applied to different patient subpopulations produces three categories of outcome: benefit, waste, and unintended harm. The trial averages these together and reports a single effect size.

Care in the real world has to discriminate between them. The framework that produced the average is not the framework that lets you discriminate.

And here is the part I find hardest to make peace with after 36 years of practice. Every patient who sits across from us is the one for whom the average can be either too generous or too thin. The framework helps us pick the treatment most likely to benefit the GROUP he or she belongs to. It does not, by design, help us figure out whether he or she is the one for whom it will quietly do nothing — or worse, do harm. The cost of that blind spot is paid in chairs and beds and chemotherapy suites all over the country, one person at a time.

In a world where current treatment is tied so tightly to trials as described above, with the predicted scattergram of results, where do we go to find a way of dealing with this complex system?

I believe the beginning of the answer lies in continuous quality improvement (CQI), which Bruce Ramshaw introduced to me over 17 years ago — a framework designed, from the ground up, to deal with complex systems rather than reduce them to questions that can be averaged.

CQI is the subject for Part 2.

“All models are wrong, but some are useful.” — George E. P. Box

There are some mornings I don’t overcome the urge to stay in bed (fortunately not as many as I used to have), but the inner voice was strong today: ‘look, you just spoke to over 100 people about reversing Type two diabetes and prostate cancer’, ‘you know you have only walked 77 minutes this week, ‘just get up, already!’ So I did…and just before sunrise, I was out of the house and heading down the road toward the river.

I LOVE early morning; I don’t necessarily like getting up, but I love the atmosphere - the early morning soft UV light, the changing hues of the sky as it lightens. And best of all…May in Florida with a breeze out of the north with a temperature of 70 degrees. So I walked - a little over 2.8 miles, with 7 episodes of sprinting for 30 seconds. Now I feel energized and awake. And the main thing is that I MOVED.

So — why is it important to move? And by movement, I mean purposeful movement like walking for 150 minutes or more per week. Our bodies are created to move; movement helps the flow of blood, it helps to keep our muscles strong (and to utilize sugar more efficiently), and it has proven benefit in overall health and longevity. I’d like to look today at how movement can help cancer patients in a number of ways, and perhaps help people stay less likely to get cancer in the first place.

The CHALLENGE Trial, published in the New England Journal of Medicine in 2025 sets the standard for showing how exercise can benefit patients.1 In this large study, involving 889 cancer patients followed over a total period of 15 years (2009-2024), randomized into two groups: one group given health-education materials, and the other group was prescribed an exercise regimen consisting of vigorous walking for 45-60 min/day 3-5 days per week. These patients had been diagnosed with high-risk Stage 2 and Stage 3 colon cancers and had received chemotherapy. The study showed several things: At a median follow-up of 7.9 years (meaning 1/2 of the patients were followed for less than 7.9 years and 1/2 were followed for longer than 7.9 years), the disease free survival was significantly longer in the exercise group than in the health education group. The five-year disease-free survival in the exercise group was seen to be 80.3% in the exercise group and 73.9% in the health-education group. The 8-year overall survival was 90.3% in the exercise group and 83.2% in the health-education group. It also showed that there was a 7.1% higher incidence of adverse musculoskeletal events in the exercise group (no surprise, but with a higher chance of living, it’s probably worth that price to pay).

An article published in February, 2025 showed that exercise benefits people undergoing chemotherapy2. In this study, it was shown that individuals who were actually undergoing chemotherapy were better capable of finishing the chemotherapy if they engaged in a prescribed exercise regimen than those who did not exercise. So while the CHALLENGE study showed survival benefit after receiving chemotherapy, this one showed the benefit of exercising during chemotherapy. In my experience (not having had chemotherapy myself), the patients who are able to exercise, meaning they work through the discomfort to continue exercising, which, by these findings, help them to finish the treatment. Perhaps it just speaks to mindset, but the benefit is real.

A large review of multiple studies3 concluded that exercise is definitely beneficial to patients who are receiving chemotherapy with regard to fatigue and overall performance status. This publication is from 2012, but the last sentence: (Further research is required to determine the optimal type, intensity and timing of an exercise intervention) is indicative of what I see as one of the problems with Medicine. Even though this large review shows definite benefit of exercise during chemotherapy, the authors are asking for more definition. Now, I don’t have a problem at all with wanting to define what exercises are better for helping cancer patients, BUT, it is well known (and has been for a long time) that walking is a great exercise when done regularly and with purpose4. To my mind, leaving the whole issue open, essentially for future definition, doesn’t really help anyone.

Another feature of movement is the increase in function of the immune system. A large review of the literature in 2024 built on earlier research by Pedersen, et al from 20165 showed several benefits in helping immune function:

• Lymphocyte Mobilization: Both acute and chronic exercise induce a rapid deployment of Natural Killer (NK) cells and effector T-cells into the bloodstream.

• The Myokine Hypothesis: Contracting skeletal muscle acts as an endocrine organ, secreting bioactive proteins called myokines (such as IL-6, irisin, and BDNF) that regulate immune cell function and glucose metabolism.

• Tumor Suppression: Studies utilizing tumor-bearing mice show that exercise-mobilized NK cells are epinephrine-dependent and actively infiltrate and inhibit tumor growth.

• Reduced Disease Risk: Epidemiological consensus attributes regular exercise to long-term immunomodulation that lowers the recurrent and incident risk of several major cancer types

Part of the immune system enhancement comes from the effect exercise has on the gut microbiome. A study in 2025, published in the journal Cell, demonstrated that exercise stimulates microbial one carbon metabolism, which creates a series of reactions, causing an enhancement of CD8 T cell-mediated immune checkpoint inhibitor (ICI) efficacy. All that to say that exercise increases the ability of the gut microbiome to positively influence the immune system in a way that helps it function against cancer cells. This particular study helped to show that exercise helped treat metastatic melanoma when it was utilized in conjunction with immunotherapy.6

The final portion for today has to do with inflammation. As has been noted, chronic diseases are almost always associated with inflammation at the cellular level (ultimately meaning inflammation leads to mitochondrial dysfunction). but, several studies have led to a better understanding of how exercise can decrease inflammation 7(in this instance, the word inflammaging in used — indicating extensive inflammation on the cellular level). It is often used in discussions regarding how to decrease inflammation in order to increase longevity (certainly a topic for another day!).

The bottom line for ANYONE who is engaged in a fight against cancer, exercise is of paramount importance. The same is true for anyone who wants to prevent cancer, or, as in my case this morning, prevent a recurrence of cancer. It has become all too easy for us to remain sedentary in this 21st century life; but the evidence is clear: in order to truly be healthy, YOU HAVE TO MOVE!! Walk 3-4 times/week for 30-45. minutes minimum. No excuses!!!

There is a growing body of evidence which shows that Intermittent Fasting may just be able to help make chemotherapy more effective while reducing its toxicity. That is a qualified statement in that the science is still evolving, but my opinion about treatment is that if it might help, is not going to be harmful — then why not try it? The early data are hard to ignore, so let’s walk through what we know, what we don’t know, and what all of this means for patients and the clinicians treating them.

The Biological Case

Normal cells respond to fasting (depriving them of nutrients) by activating protective mechanisms: slowing their metabolic activity, increasing cellular repair (a mechanism called autophagy, which will be another essay), and essentially hunkering down — think of a bear going into hibernation. The longer the fast, the more those type of changes occur. Cancer cells are driven by their relentless drive to grow and their dependence on glucose and insulin signaling and cannot make this shift into a protective mode and are thus metabolically exposed.

This difference in the way normal and cancer cells deal with the stress of nutrient deprivation is the theoretical cornerstone of fasting as an adjunct in cancer therapy. Fasting induces a metabolic shift that may inhibit cancer cell growth by depriving those cells of essential nutrients, while also promoting autophagy (cellular healing) in normal cells which, in their ‘clean-up mode’, can damage cancer cells.1 In animal models, the results have been striking. Fasting has shown promise in reducing tumor growth, improving the effectiveness of chemotherapy, and enhancing overall survival in rodent models. (And I KNOW people aren’t rats!! Just go with this thought for a while).

There is a well documented Fast Mimicking Diet (FMD), initially developed by Dr. Valter Longo (from USC Davis School of Gerontology) which is a structured, low-calorie, low-protein dietary protocol that mimics the physiological state of fasting without complete food abstinence. The FMD reduces plasma levels of IGF-1 (Insulin-like Growth Factor-1), insulin, and glucose — all of which are key mediators of cancer cell growth and progression.2 These effects on IGF-1, insulin, and glucose are precisely the hormonal signals that make tumor cells vulnerable and normal cells resilient.

What the Clinical Trials Show

The landmark human study is the DIRECT trial, which is a multi-center, randomized phase 2 trial published in Nature Communications. Researchers randomized 131 patients with HER2-negative Stage II/III breast cancer to receive either a fast-mimicking diet or their regular diet for three days prior to and during neoadjuvant chemotherapy (chemo given before other treatments, like surgery). A radiologically partial or complete response occurred more often in the FMD group, and per-protocol analysis, revealed that a pathological response indicating 90-100% tumor cell loss was significantly more likely in patients using the FMD. The FMD also significantly reduced chemotherapy-induced DNA damage to T-lymphocytes (these are some of the most important cells in our immune system which help to fight cancer, and are some of the first to be damaged by chemotherapy).3 My thought: If fasting can indeed protect the immune system during treatment, then it might prove to be a critical consideration for long-term outcomes.

Beyond tumor response, there is emerging data to indicate that relief of symptoms may occur with intermittent fasting interventions. Fatigue, nausea, vomiting, diarrhea are not uncommon during chemotherapy. Intermittent Fasting shows early promise with helping with those symptoms. Emerging evidence also shows that Intermittent Fasting may reduce DNA damage and induce favorable cellular-level immune response to help fight cancer. Phase 1 and 2 clinical trials have shown that cyclic FMD is safe, feasible, and associated with positive metabolic and immune system effects in patients with different tumor types.4

Where the Evidence is Still Incomplete

A 2025 systematic review confirmed the safety and feasibility of Intermittent Fasting in cancer patients but ended up with the conclusion that a definitive statement regarding the impact on treatment effectiveness and chemotherapy-related toxicities could not yet be made. Larger randomized controlled trials are needed, they said.5 Most studies to date have focused on breast cancer, and you can’t really apply that information to all other tumors or all chemotherapy regimens. Also, patients with low body weight, significant treatment-related weight loss, or cachexia (large amount of weight loss in late stage cancer patients are NOT good patients for fasting protocols. Malnutrition during active treatment is a real risk that must be carefully weighed by the treatment team.

More structured fasting protocols around chemotherapy infusion days — such as the FMD approach used int the DIRECT trial — require medical supervision, nutritional monitoring, and an oncology team willing to engage with the evidence. Finding clinicians open to that conversation is, regrettably, harder than it should be.

What This Means for Your Oncologist

If your oncologist hasn’t raised this topic, it is not because the evidence doesn’t exist — it’s because nutrition and metabolic intervention remain under the radar for most physicians due to the lack of nutritional teaching in medical school as well as in residencies. It’s also under the radar due to the lack of large studies to evaluate it. The situation is changing, but slowly. The data from the DIRECT trial and the growing body of clinical trial literature are very gradually becoming part of the conversation in mainstream oncology. It’s going to take time and it’s going to take discussions, encouraged by patients who want to have those discussions openly and honestly with their doctors.

The Bottom Line:

Intermittent Fasting as an adjunct to chemotherapy IS NOT fringe medicine. It is an evidence-informed strategy which is grounded in sound science, is supported by meaningful clinical data, and is — most importantly — safe when applied properly. For patients willing to engage with the biology of their own cancer, it is certainly a conversation worth having and an arrow in your quiver which might just help the fight against cancer.

If it’s SAFE, if it’s NOT going to cause harm, and it MIGHT help — why not try it??!! Truthfully, the only way medicine the way it is practiced in this country is going to change, is for patients to push for it. Safety is paramount; but the truth is that longitudinal (meaning observational, over time) studies can be as effective as randomized, controlled studies performed at the cost of millions (or tens of millions of dollars. After all, what entity is going to benefit from something that doesn’t really cost a lot of money?

If every adult in this country could start to learn that chronic diseases (even cancer) are usually a self-inflicted wound and that by taking an active interest in health, as well as taking control over their own bodies, then we might become healthier than ever before. We might be able to decrease the numbers of people contracting cancer. We might provide a higher opportunity to treat cancer effectively, and we might be able to approach true longevity with Lifespan as well as Healthspan.

As you know, I’m a General Surgeon, not a Urologist, so I only had a vague understanding of the Gleason score used in diagnosis of PC. I knew it was reported as a combination score of the two most prominent cell changes seen in the slides, with three being the least malignant and five being the most malignant. So…I had mostly five with a smattering of four, to get to the Gleason 9 (5+4), but really more like a 9.8 — great in diving competition, but not so much in PC. Having been a surgeon at that point for over 30 years, I didn’t panic at first with the diagnosis…I had seen the MR and knew it was most likely a cancer, though that thought was still somewhat surreal in that it was MY cancer, not someone else’s. So I thanked the pathologist for his words of compassion and then went to find out what it all meant.

After reading numerous articles from PubMed, where most medical literature resides, I found that Gleason 9 tumors have mortality at five years which increases by 10 years and after. The death rate was not nearly as high as many cancers I have treated over the years, but it indicated that it needed to be dealt with (not necessarily quickly), but decisively. I also read there were treatment options, either of which were essentially equally effective: radical prostatectomy (removal of the prostate as well as pelvic lymph nodes) OR a combination of full pelvic radiation followed by two years of Androgen Deprivation Therapy (ADT), which completely depletes your body of testosterone, the main male hormone. Hmmmm…none of it sounded appealing, just like the alternatives I had always offered to patients weren’t likely to be appealing to them either, but here we are. I had an older type of PET scan which can show if there are metastatic lesions (this older one, the Axumen Scan is now replaced by the hugely more sensitive PSMA scan). My PET scan showed no evidence of spread anywhere.

Ultimately, in consultation with Medical and Radiation Oncologists, as well as my surgeon, I opted for the surgery…mainly because, as a surgeon, I trusted the operation and I also wanted confirmation with the lymph nodes being removed, that there was no further disease lurking (at least none that could easily be found). So…three months after the diagnosis, I underwent a Radical Robotic Prostatectomy by an excellent surgeon at the Mayo Clinic Jacksonville who was personally known to my Urologist. The surgery went well (with one small hiccup during the night after the operation); I ended up staying two nights, then going home.

Two weeks later I was recovering well and I returned to seeing patients in less than 4 weeks, not 100% fully recovered, but more than enough to function 100% at what I limited myself to doing. Six weeks after surgery I was completely functional, except I was still incontinent of urine and still using a diaper - which completely resolved in the next few months. The pathology report was great: Gleason 9 PC, completely removed, with clear margins and all ten lymph nodes removed free of any cancer. Yay! But, as the surgeon and I had discussed, I knew there was a 50 % chance of recurrence in the first five years, even with this result. But for the present…no need for other interventions. Two years of ADT was still one of the possibilities as adjuvant therapy, even after a great surgical pathology report, but I decided against it. And here I would caution any readers that my decisions were based on what I thought best for me — not necessarily for anyone else. The key thing to remember is that I personally encourage anyone with any medical problem, especially cancer, to become fully involved in their treatment decisions. Ask questions, do your own research and ask more questions.

I definitely felt relieved after seeing the path report, but in the post-operative recovery time, I had time to process everything. Having grown up in a Christian home and having honed my own faith throughout the years, I really had no fear of dying (not that I want to die any time soon, but I was not fearful). Checking within myself, I found minimal fear just prior to the operation…because the OR is my place and it wasn’t unknown — and I had watched several hours of YouTube videos of the operation so I had a great working knowledge of it. Fear most often occurs in the face of the unknown, so I claim no super power in not being fearful of the surgery. However, in the quiet days and weeks after the operation, I had plenty of reason to reflect on my own mortality. As a patient of mine who had stomach cancer (recurrent times two after two operations) said, “I know where I’m going, I just want a safe landing”.

So there it was — my unknown, and unknowable ultimate outcome from the cancer. The best I could do at that point (at any point, really) was to live day to day and to trust. Trust that God is involved in my life and that He will provide for whatever I need, whether it is support and comfort if my life is shortened by the cancer, or if it’s guidance as my life goes on. What I found in that time was that faith is real, that God is trustworthy — not because I lived to see another day — but because He is present in our lives if we just seek Him. As much as anything else, that faith undergirded my whole experience and helped me ultimately find peace in whatever circumstance I found myself. If you’re thinking that it isn’t that easy, I can tell you differently. I have seen hundreds of people die over the years — acutely in trauma situations, over long periods of time due to the ravages of metastatic cancer, or due to chronic diseases which cause progressive loss of function. I watched it with my grandparents, my parents, and my sister. If you have faith that God is present in all circumstances, then the particulars lose their power of fear. NO ONE wants to be in pain, in misery, to waste away, but what I found inside was the hope the apostle Paul referred to as ‘peace that passes all understanding’ in relationship to believing in the salvation offered by Jesus. I know I’m touching on sensitive ground, but as a physician, I would be remiss if I, as a believer in God and salvation through His Son, didn’t mention this aspect of my experience. If nothing else, it re-affirmed my faith — even before the pathology report came out.

My life returned to normal and my PSA was undetectable (reported as less than 0.1) within 3 weeks of the surgery, then at 3, 6, 9, and 12 months afterwards. At 18 months it was 0.1 — very low, but not undetectable. At 21 months, it was 0.2. Something was happening. In order to find out where the cancer was, because only a recurrence would cause those lab changes, I had that new scan, the PSMA (Prostate Specific Membrane Antigen) which shows if there are any prostate cells around — usually. Without a prostate, the only prostate cells around would be cancerous. My scan showed that four lymph nodes in my pelvis had tumor in them; not much, but any is obviously cause for concern. As I mentioned in an earlier essay, I chose to have two injections of ADT with all the attendant side effects: extreme fatigue, significant hot flashes, weight gain, but thankfully, no mood changes. So…did this finding, which confirmed how difficult it is to deal with a Gleason 9, change my outlook on life? No…but it gave me cause to reflect on the blessings of my life and that I wasn’t ready to give them up at age 68. I had no overarching fear — rather a tightening resolve to fight it. If you read the beginning essays, you will know much of this, but what I hope to show is that while we are in the midst of troubled times, we can rely on a ‘higher power’ and that what FDR said after Pearl Harbor is indeed true: “The only thing we need to fear is fear itself!”.

It didn’t happen right away, but what I learned about medicine as it exists is that in most Western countries, and especially in the USA, we, the physicians, have forgotten our herbalist, holistic, naturopathic roots (or had them trained out of us). We have become more and more algorithmic, meaning we follow guidelines which are designed to function for the masses, not so much for individuals. These guidelines are set first (usually) by CMS (Centers for Medicare and Medicaid), which are then followed by most insurance companies. As more and more doctors are now working for companies owned by venture capitalists, the algorithms take on an importance which is far more than they warrant, just because it’s easier to track ‘data points’ than it is to look at patient outcomes. Someone may be diagnosed as ‘pre-diabetic’ and then placed on Metformin AND a statin…because a study done somewhere (not atypically due to funding by a pharmaceutical company) shows ‘good’ results…and the algorithm begins. Every visit after that is aimed toward looking at the disease process and to treat it progressively with the algorithm. It is in this setting that doctors (or physician assistants, or nurses practitioners) functionally become overseers of the algorithm, which is further worsened by a system that rewards “efficiency” meaning limited time for each visit in any doctor’s office.

The typical patient trajectory in this system is that he/she will have progressive disease which ‘requires’ more medications; more powerful anti-diabetic meds, increased statin dosage, addition of one, two, or three meds to treat high blood pressure — all with minimal explanation of lifestyle changes other than lip service to ‘eat better and exercise more’ — WHICH ALL OF US KNOW IS CORRECT! The reason this can happen is easy to see: we live in a time and society where “I want it now” serves as the mantra of life. Fast food, easy dinners, fast scrolling, less exercise, more artificial (LED) light, less sleep, less quiet time, less reliance on a higher power. In this society, it is very easy for patients and doctors alike to grasp onto algorithms: it’s easier for patients to hear they need more meds to ‘make them better’ and easier for the medical professionals to just give them out instead of becoming coaches on how to change lifestyles. As I said, there is more money in tracking data points than in patient outcomes. The combination of an individual’s desire for a quick fix without any significant effort other than putting a few pills in the mouth and the doctor’s desire to show efficiency and efficacy based on the data points of the algorithm makes our current situation virtually inevitable (I was a victim of it in my own life and also as a professional — I was on both sides of that equation as well). I am NOT saying that medications are NEVER needed! That’s not true. I’m just saying that we don’t need to have over 50% of the adults in this country dealing with a preventable, reversible chronic disease like Type 2 Diabetes.

I have, for years, bought into the concept that if you identify a problem, name the problem — you should become part of the solution. Which is why I elected to retire, start writing these essays, and to start Sunrise Institute. Because the answer isn’t in trying to change the Medical/Pharma/Hospital Industrial Complex — there is simply too much money at stake to do so easily and besides, you have to look at the patients. How many people are REALLY willing to change everything about their lives: how they eat, what they eat, how they exercise, how they sleep, how they approach mindfulness (prayer, quiet time), and how they deal with stress? The MPHI Complex is betting on not many. My strong belief is that many more actually ARE willing to change, once they have a diagnosis and prescriptions they don’t really want — dealing with diabetes, heart disease, high blood pressure, chronic arthritis, and cancer.

That people can and will change when presented with good information and instruction is my belief, and witnessed by my own experience. Now, 30 months after the last ADT injection, through a complete change in how I live my life in all the parameters I mentioned above, as well as the addition of (gasp) repurposed drugs and supplements (again I refer you to Dr. Paul Marik and Jane McLelland — among others), my PSA remains undetectable. Due to these changes, it is my belief that the course of my diseases (both Type 2 Diabetes and a very high grade PC) has been altered. Will the PC remain checked? Will my Type 2 remain controlled without meds? Only time will tell, but I can tell you that I feel better than I did 30 years ago, can function at higher level physically, and with a higher degree of mental clarity.

Change CAN occur. If I can do it — as addicted to food and as inactive as I was by choice — just about anyone can do it. I’m still a work in progress, but progress has been made. With the right motivation (health) and the right information, this type of result is likely attainable for many, if not most people. My answer to the question regarding the medical system isn’t that we can force a change in the whole thing over a short period of time, but rather, it can be changed by one doctor and one patient at a time, making a concerted, joint effort in dealing with disease. The answer is the same one as the old question: how many psychiatrists does it take to change a lightbulb?

One, but the light bulb has to want to change!!!

I invite you on this journey with me — I intend to explore different aspects of ‘the new medicine’, particularly that which has drawn me inexorably to this place in time — integrative oncology. No one therapy, likely no particular combinations of therapies, is going to succeed in all patients with any given type of cancer. There is a large chasm between traditional oncologists and those of us who see there are different pathways to potential healing. It is my goal, stated here and now, to start to bridge the chasm and to help patients not only live longer lives in the face of cancer, but to live better, healthier lives as well. What all doctors want, more than anything else, is to do the absolute best thing possible for each patient, as do I. Despite the faults of the system, the individual doctors (at least the ones I know) are dedicated to healing. Having dealt with cancer in my own body, having operated on several thousand patients with cancer, and now, having walked through cancer (via traditional and integrative care) with a dozen patients over the last year, I can say there is hope on the horizon. I have attended three funerals of individuals who succumbed to Stage 4 cancers despite the best efforts of some of the best oncologists I know, and despite making some of the changes discussed above. Those losses are devastating to the families left behind and have been a sober reminder for me that we are all mortal, we are all human and we have much to learn in this new paradigm of treatment. Those three men had become part of the fabric of my life and my prayers. I hold them and their families close to my heart and will continue to do so. The pain is real.

Over the next months, I intend to explore different aspects of Integrative Oncology (like the last essay on Insulin Resistance and Cancer), so that we can walk through this together. If you have cancer, or you know someone who does, please tell them about this Substack. I purpose to help build not just a company (my Sunrise Institute), but to build a community of like-minded, purpose driven people.

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has.” — Margaret Mead

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I ate my way into Type 2 Diabetes. Then I ate my way into Prostate Cancer. Those are harsh statements, and of course, it’s always more complicated than that, but still, there is so much truth in it that I can state it and own it. Type 2 Diabetes is a metabolic disease and over 90% of all cancers are metabolic in origin (more about that in a later post). As I related in the first post, I gradually progressed with Pre-diabetes, then full blown diabetes — before I learned that I could reverse it. Learning and doing are two different things, of course, which is always the problem in the human condition. Even after I had begun the reversal, I wasn’t really involved in a totally healthy regimen in my life. So the cancer occurred. It could have been for any number of reasons, but mainly because of what I know now — that the metabolic ‘terrain’ for cancer is just a continuation of the same terrain for diabetes and other chronic diseases.

Even as a doctor, I didn’t think deeply about the fact that diabetes and cancer can be connected by the same biology. I believed (naively) that diabetes is about blood sugar and cancer is about genes and genetic bad luck (which in some cases it is). What I didn’t understand was that long before the blood sugar climbs too much past normal, your body can have an excess of insulin (the hormone made in the pancreas which pushes glucose - sugar - into cells). When you eat sugar (or other carbs), more insulin is produced in the pancreas. If you continue that way of eating, so much insulin is produced that your cells become resistant to the insulin; insulin levels increase and stay high, and sugar gets placed in other organs, leading to fatty liver and so call ‘visceral fat’ (stubborn belly fat).

But insulin isn’t just for ‘handling’ sugar, it is a powerful growth signal. When I say I ‘ate my way’ into these illnesses, I’m not talking about one meal or one holiday, I’m talking about years of repeated, insulin-spiking choices — fast food, ultra-processed foods, snack foods, and the like. I could easily justify the eating of all those things because I was busy, tired, or stressed. The result of those years was that I became insulin resistant: my cells stopped responding normally, so my pancreas had to produce more and more insulin just to keep my blood sugar ‘relatively’ normal. And I’m not alone: over 100 million adults in the US are diagnosed with type 2 diabetes or pre-diabetes. At least 8 million adolescents under age 20 have pre-diabetes. As a nation, we are a metabolic mess.

What insulin actually is — beyond sugar

In addition to its effect on sugar, insulin is one of the body’s strongest signals for growth and storage. In the short term, that’s useful to move nutrients into cells and support repair, but the problem is the chronic elevation. With insulin resistance, caused by chronically elevated levels of insulin, the cells don’t respond the same way and the pancreas responds by increasing the volume of insulin to the point insulin in the blood remains elevated and over time just doesn’t diminish. Blood sugar may look only mildly abnormal for a while, but the insulin level can be high for years before a person is diagnosed with ‘pre-diabetes’. In other words, the body can be broadcasting this powerful growth-and-storage signal (insulin) continuously, even before someone is officially diabetic.

So how does this extra insulin impact cancer? Many cancers occur because of what is called ‘epigenetic changes’, meaning, there are changes around the DNA which lead to a cancer cell forming, whether it’s because of a fault in the DNA when the cell divides (which all cells do at different rates), or because of a poisonous change around the individual cells which causes changes leading to cancer. All of those things, added to the chronically increased insulin hanging around, matter — because cancers don’t just grow randomly, they respond to signals. Insulin, along with a related growth factor (called IGF-1 — Insulin Growth-like Factor 1), can cause effects encouraging cancer cell growth. . IGF-1 is, in most circumstances, an important in maintaining overall health and is beneficial. However, if increased IGF-1 is present over a prolonged period of time, bad things can happen. When insulin and IGF-1 are chronically elevated, they can cause effects involving three pathways that cancer uses to grow and spread: cause increase cell division (cell proliferation), they can inhibit apoptosis (fancy word meaning cell death — cancer cells become immortal and helping them to remember how to die is an important thing in oncology), and they create an environment to support angiogenesis (the creation of new blood vessels which allows tumors to grow faster and larger).

I’m not saying that insulin causes cancer; I’m indicating that increased insulin in circulation can change the metabolic terrain and thus set up situations which allow an early, undetectable cancer to grow. Excess insulin also leads to increased inflammation. I want to spend more time on the term inflammation (which is not the same as infection) at a later time. For now, just understand that inflammation is bad for the body and leads to chronic disease because it changes the environment around cells which makes it easier for problems to persist and harder for the body to maintain normal checks and balances.

The fact that insulin resistance is associated with many cancers is now well documented (Five articles are referenced at the end of this post). Many cancer patients are measurably insulin resistant; insulin resistance is associated with worse outcomes — higher recurrence rates and lower survival. Remember: a person can exhibit insulin resistance and not technically be diabetic. The fact that this aspect of physiology is not discussed routinely with cancer patients is not the fault of any particular physician; rather it’s part and parcel of the medical system as a whole. This point may be considered small potatoes in the overall landscape of a cancer diagnosis and in the treatment of the disease, but the way I encourage people to look at is that IF there is something relatively easy for someone to work on and therefore increase their survival (even just a chance to do so), then why not do it?

I firmly believe cancer patients must be given every opportunity possible to increase their knowledge of their disease process and to engage in their own care.

Three concrete things you can do to fight back against insulin resistance:

1. Reduce foods that spike insulin: decrease sugar (to as close to zero as possible); eat fewer refined carbohydrates (bread, pasta, rice); eat fewer ultra-processed foods (which can be broadly defined as just about anything contained within a box or a bag). All these foods rapidly increase blood sugar and therefore insulin.

2. Consider fasting (only in conjunction with your physician’s involvement). Why is this important? The longer you go without food, the less sugar you have in circulation, the less stimulus there is for insulin to be released by the pancreas, and over time, insulin resistance diminishes. So — if you eat dinner at six, and you don’t eat again until 7 AM, you are fasting for 13 hours. If you can get to lunch without any food, that can be 17-19 hours. The longer the fast, the more you fight insulin resistance and the more you help your body fight back against cancer. I will come back to the concept of fasting at a later time, because it deserves its own place in your arsenal, but for now, just learn how to help yourself in this manner.

3. Move. Consistently. Daily. Exercise is one of the most effective insulin-sensitizing interventions we have to use. Walking is GREAT exercise (walking with purpose — to gain speed and distance). 150-180 minutes per week (or more). Walking after meals, adding in resistance training (weight lifting), cycling, swimming — any regular exercise helps your muscles use sugar more effectively and thus reduce the need for your body to produce insulin.

I’m not saying that all of this points to a cure, but I can tell you that as I learned all this information as I dealt with my own cancer (no one told me then about this stuff, I was on my own to find out), it is one of the things that has allowed me to be healthier than I have been in 30 years. And it has been part of the regimen that I have followed to help myself stay free of recurrence of a cancer that wants to recur.

If you have cancer, or know someone who does, please use this information. If you have questions, please contact me, either here (or on my website: (sunriseinstitute.com). Everything we can do for ourselves to help our bodies decrease the chance of getting cancer, or to fight it if there’s a diagnosis, is a very good thing. Ask questions; do your own research, and ask more questions!

Press on!

Articles for reference:

Cosmin Stan M, Paul D. Diabetes and Cancer: A Twisted Bond. Oncol Rev. 2024 May 21;18:1354549. doi: 10.3389/or.2024.1354549. PMID: 38835644; PMCID: PMC11148650.

Màrmol JM, Carlsson M, Raun SH, Grand MK, Sørensen J, Lang Lehrskov L, Richter EA, Norgaard O, Sylow L. Insulin resistance in patients with cancer: a systematic review and meta-analysis. Acta Oncol. 2023 Apr;62(4):364-371. doi: 10.1080/0284186X.2023.2197124. Epub 2023 Apr 12. PMID: 37042166.

Chiefari E, Mirabelli M, La Vignera S, Tanyolaç S, Foti DP, Aversa A, Brunetti A. Insulin Resistance and Cancer: In Search for a Causal Link. Int J Mol Sci. 2021 Oct 15;22(20):11137. doi: 10.3390/ijms222011137. PMID: 34681797; PMCID: PMC8540232.

Mirzaeva, M., Iriskulov, B., Asrorov, A., Hudoynazarov, I., Norbekova, M., Tadjibayeva, R., & Mirzaev, A. (2025). Association of Obesity with Premenopausal Breast Cancer: Analyzing Molecular Subtypes: Obesity and metabolic markers in BC. Archives of Breast Cancer, 12(4). https://doi.org/10.32768/abc.8063149720-581

Arcidiacono B, Iiritano S, Nocera A, Possidente K, Nevolo MT, Ventura V, Foti D, Chiefari E, Brunetti A. Insulin resistance and cancer risk: an overview of the pathogenetic mechanisms. Exp Diabetes Res. 2012;2012:789174. doi: 10.1155/2012/789174. Epub 2012 Jun 4. PMID: 22701472; PMCID: PMC3372318.

I am personally still somewhat perplexed by all the names. There’s Osteopathic Medicine (involving manipulation of the musculo-skeletal system as well as diagnosis and treatment with medications), which is actually MUCH more like Allopathic Medicine than it has ever been. There is Chiropractic Medicine (formal training on mainly manipulation of the bony structures — now many are transitioning to Functional Medicine). Then there is Functional Medicine (devoted to root cause analysis to identify disease process and search for changes that can modify those diseases at a deep physiological level). There is Integrative Medicine, which I see as a combination of all the above. There is Lifestyle Medicine — which is largely based on nutrition in that it gravitates mainly to a plant based diet — as well as the other factors we know about including necessity of sleep, exercise, and mindfulness. There is Naturopathic Medicine which looks at disease and treatment from a holistic, herbalist approach (I know I’m simplifying). And there is also Traditional Chinese Medicine (TCM), which I truly believe we should pay more attention to and something I am learning more about — which also includes acupuncture.

I knew virtually nothing about all that in 2023. Yes, I was peripherally aware of those others but I was busy as a surgeon and perfectly content to be doing what I did on a daily basis. In November of that year, I found (nearly at the last minute) about a meeting in Ocala, Florida (60 minutes from my house). The meeting was called The Florida Summit, put on by Dr. John Littell, a Family Medicine doc in Ocala. I had vaguely heard of many of the speakers, but was most familiar with Dr. Joseph Ladapo, the Florida Surgeon General and Dr. Robert Malone. It was there that I first heard Dr. Pierre Kory and Dr. Paul Marik speak, as well as many others over the course of the day. What I found out was that my friends and I had NOT been crazy when we questioned all the Covid lies Medicine had been putting out since 2020. I had found soul brothers and sisters who cherish life, cherish being doctors, and who had fought against the machine of the medical-pharma-industrial complex. It was a reorientation to my roots in medicine and was an eye-opening experience which engaged my curiosity on a level I hadn’t experienced since medical school and residency.

I was also vaguely familiar with the FLCCC (Front Line Covid Critical Care) doctors, but meeting Drs. Marik and Kory got me a lot more interested. I left the meeting inspired, but without any particular direction — I was a surgeon who loved his profession — but something was stirring inside. So, following my instincts, I started reading, beginning with Pierre Kory’s book “The War on Ivermectin”. All of which stimulated me to look more into the FLCCC. I found an FLCCC* meeting that was to take place in spring of 2024 in Arizona. There, I found my people again — both lay folks and medical folks as at The Summit. Paul Marik’s first words were something to the effect that ‘our medical system is corrupt’. Yes, yes it is: with the CDC, NIH, and the FDA and their research arms being financially tied in many ways to Big Pharma; with the media paid for by Big Pharma (I finally understood WHY the ads on television were promoting meds that lay people don’t understand, remember, or can prescribe for themselves) which gives the pharmaceutical industry hundreds of millions of dollars of leverage. And with Big Medicine (the medical Boards, the AMA, The American Heart Association, as well as many others) being more about self aggrandizement than taking care of patients — medicine is as far away from the days of Marcus Welby, MD as we can possibly be. Corporations have taken over even more in the last two years.

At that meeting, I also listened to a talk by a physician who had given a patient with Stage 4 prostate cancer which was not responding to traditional therapy, Ivermectin daily. 18 months later he was almost completely free of disease. I was listening intently and was, needless to say, very impressed. Even more impressive was that the next speaker was the patient himself, who told his story of hope and survival against all odds. Talk about making your head spin. I was only about 6 months out from my last injection of the ADT and was still experiencing hot flashes, so it definitely got my attention.

I purchased about 20 books over the next few months. The ones that made the most impact at the time were “Chris Beat Cancer” by Chris Wark, who was 26 when he had part of his colon removed for Stage 3 colon cancer, refused chemotherapy, and who essentially cured himself with a strictly plant based diet. There was also “Cancer Care” by Dr. Paul Marik, one of my guiding lights in this New Medicine, then in its first addition. And there was “Lies My Doctor Told Me” by Dr. Ken Berry, a Family Medicine doc in Tennessee. I’d recommend the first two for anyone diagnosed with cancer, and the last one for everyone who has an interest in the “New Medicine”.

As I learned more about true health, and how to get there, I got healthy for the first time since I was in medical school. I started eating the right way (not just to reverse my Type 2 diabetes, but to truly get healthy), I started paying attention to my sleep, and also to proper exercise…I started walking 3-5 times/week at least, in addition to continuing resistance training (lifting weights) which I had actually begun in January 2022. As I got healthier, I got rid of all my meds, started taking supplements I had learned about, and I lost what I would describe now as ‘brain fog’ — not really a diagnosis in my case, but my thinking became clearer and I experienced a reversal of physiological age ( when I turned 70 in 2024, my physiological age was estimated to be 61.5). My weight returned to what it had been nearly 40 years before — meaning I lost about 50 pounds over time. I’m not finished with that conversion to health, but for the first time in my life, I have been consistent with eating properly and exercising.

With the loss of the brain fog, my energy for new projects returned and I began putting together a course (to be put online) to teach patients about prostate cancer from the standpoint of a doctor who had become a patient. I also went to the 20th edition of the Integrative Health Symposium held in NYC every February. That meeting helped solidify my intention to pursue the New Medicine, but still not with any clear direction. But I continued to read, and even more importantly, started spending time with a few patients talking about their health. I gradually started seeing more patients with significant health issues who wanted to hear what I had to say and I started spending more time talking with them about their health than I did talking about their surgery.

What I found was that most people really don’t want to take a fistful of medications every day and many are very willing to make the significant changes in lifestyle necessary to get off of them. It was in those early situations that I learned to be a partner with patients in developing their health, rather than just an ‘expert’ telling them what to do. I’d always had teaching moments with my surgical patients, but it was based on having a conversation — something which has been missing in much of ‘Traditional Medicine’ for a couple of decades. Like I said, I was gradually returning to my roots — the naive teenager, then medical student, then resident, who was wowed by anatomy, physiology, and the ability to look inside a human body to try to understand its workings, was now back and not naive.

I was waking all the way up.

(*now called the IMA — Independent Medical Alliance, found at ima.org)

I intend to delve into these concepts further over the next few weeks and months as I get Sunrise Institute up and running. My purpose with Sunrise Institute is to add into the equation of helping people mired in a system (as well-meaning, expert, experienced, and compassionate as the practitioners of said system are) which is less informative and helpful than it should be. Along the way, I will introduce how I increased my knowledge of this topic and became passionate about it; I will also introduce you to the concepts I was fortunate enough to have learned from Dr. Paul Marik (who’s Substack I urge you to follow) as well as Jane McLelland (whose Substack is also worthy of following) — two of the true heroes of integrative oncology. It is a growing circle of folks who are dedicated to helping people walk through a diagnosis of cancer and I am humbled as well as honored to throw my hat in the ring.

This is one of the articles I read in 2023 regarding the use of Graviola in the treatment of cancer. If you read anything of it, read the conclusion.

Asif Khurshid Qazi, Jawed A Siddiqui, Rahat Jahan, Sanjib Chaudhary, Larry A Walker, Zafar Sayed, Dwight T Jones, Surinder K Batra, Muzafar A Macha, Emerging therapeutic potential of graviola and its constituents in cancers, Carcinogenesis, Volume 39, Issue 4, April 2018, Pages 522–533, https://doi.org/10.1093/carcin/bgy024

This is one of the articles regarding the use of Lactoferrin in treating cancer:

León-Flores DB, Siañez-Estada LI, Iglesias-Figueroa BF, Siqueiros-Cendón TS, Espinoza-Sánchez EA, Varela-Ramírez A, Aguilera RJ, Rascón-Cruz Q. Anticancer potential of lactoferrin: effects, drug synergy and molecular interactions. Biometals. 2025 Apr;38(2):465-484. doi: 10.1007/s10534-025-00672-y. Epub 2025 Mar 21. PMID: 40117096; PMCID: PMC12266083.

The following article is from 2023 regarding the use of IP6:

Dilworth L, Stennett D, Omoruyi F. Cellular and Molecular Activities of IP6 in Disease Prevention and Therapy. Biomolecules. 2023 Jun 10;13(6):972. doi: 10.3390/biom13060972. PMID: 37371552; PMCID: PMC10296680.

And finally, this article is about the use of Indian Gooseberry:

Kumar G, Madka V, Pathuri G, Ganta V, Rao CV. Molecular Mechanisms of Cancer Prevention by Gooseberry (Phyllanthus emblica). Nutr Cancer. 2022;74(7):2291-2302. doi: 10.1080/01635581.2021.2008988. Epub 2021 Nov 28. PMID: 34839775; PMCID: PMC9341453.

These articles are JUST the beginning of what knowledge we have about medications to treat cancer as shown in the medical literature. In his book “Cancer Care — Use of Repurposed Drugs to Treat Cancer”, Paul Marik has 1,314 literature citations. Jane McLelland, in her book “How to Starve Cancer” has hundreds of references as well. I find it notable that I don’t remember seeing any of ‘my first four’ in either book, which shows how far we have to go to understand what we really have on hand to bring to bear against cancer.

The vast majority of the natural substances (like the four above) and the repurposed drugs have HUGE safety profiles. Their side effects tend to be minimal, and usually dose-dependent (which essentially means you have to take a massive dose before any side effects occur) — and when there are side effects, they are not the ones we associate with medications used to treat cancer.

As I mentioned, I had started taking supplements which had been shown in mice to be effective in increasing the cell death of prostate cancer cells (as well as breast cancer and other types). Mind you, this is NOT randomized, controlled human studies, but it was enough for me to say that I wanted to stop the ADT and keep taking the supplements. The first one I found was: Graviola (tropical sour sop); next was Bovine Lactoferrin, soon followed by IP-6 Gold and Indian Gooseberry (Amla powder). Articles that I found at that time to back these claims are included at the end of this essay.

So, I started taking all of them soon after I got the first injection of ADT in July 2023. In September, my PSA was tested and it was again undetectable. Not knowing whether it was the ADT or the supplements, I took the next injection as per my pre-treatment plan and continued to experience the side effects. After the next three months, my PSA remained undetectable and I stopped receiving the injections. I was told to call the oncologists ‘when my PSA goes back up’. As of last month (28 months after my last injection, and now 4 1/2 years after my surgery, my PSA remains undetectable. I have changed my supplements around as per new knowledge, and I have changed my lifestyle completely (to be addressed in future posts). How do I explain having a Gleason 9 prostate cancer which recurred in lymph nodes 18 months after surgery and now still gone 28 months after only 6 months of ADT? Is it good fortune, is it the ADT, is it the supplements and lifestyle changes I made? I am now an anecdote. I’m not a lab rat, nor am I a randomized, controlled study. What I AM however, is cancer free.

What I started to learn in July/August of 2023 and have continued to learn since then is that traditional allopathic medicine does not seem to have all the answers. I was told that I would need a series of treatments (starting with the surgery) that would eventually require prolonged hormone therapy to empty my body of testosterone (with the knowledge that at some point, prostate cancer develops a resistance to this therapy known then as ‘castration-resistant metastatic prostate cancer), extensive radiation therapy to my pelvis, and yes, even chemotherapy (perhaps) down the road after the others fail.

After the ‘ontological shock’ of what I’d experienced during Covid in 2020/21, followed by the cancer diagnosis in later 2021, followed by the revelation of possible other therapies which were not acknowledged by regular medicine, I started looking at this other world. The next step on the journey was to attend a ‘Covid Summit’ headed by Dr. John Littell (a family doctor in Ocala, Florida). It was not his first ‘summit’, but I had heard about it and it was only an hour away, so off I went. There, I met several renegades who I had heard about during Covid, but never expected to actually meet in person: Dr. Robert Malone (and his lovely wife Jill) (Who is Robert Malone?), Dr. Pierre Kory (Pierre Kory’s Medical Musings), Dr. Paul Marik (Cancer and Metabolic Healing), and Dr. Ryan Cole. If you look at Google (or Wikipedia), you will see that these men have all been defamed, some have been defrocked of Board Certifications, and generally dragged through the mud. I have met them (some more than once), and have had conversations with them, in addition to reading their books (and their writings on Substack). I can assure you all of them are incredibly intelligent, diligent, well-researched, as well as thoughtful and very dedicated to improving the lives of those they touch. Please hear me on this: debates about science, about medical science, about treatments, and research ARE NOT disinformation. You can disagree with someone who holds a different opinion, but don’t shy from the debate and retreat behind a keyboard or a medical facade and defame that person.

What I learned at The Summit was that indeed there is a whole world of information, based on science, open to discussion and debate (as science should be), and that I wanted to learn more. Since late fall 2023, I have attended numerous conferences, read all or parts of over 40 books, and had numerous conversations with people on the leading edge of this new take on medicine. What started as a search for my own treatment has evolved into a deeper love of medical knowledge than I’ve experienced since the first days of medical school and residency. As I have become healthier through my own efforts and growing knowledge, I have gained more energy and enthusiasm for learning and teaching than I have in a long time. I have also developed a strong desire to step out and do things like write a Substack that only a few people even see, work toward opening my own online clinic through Sunrise Institute (sunriseinstitute.com), and having daily conversations with people who have experienced the old system and see the need for change.

As I said in Part One, I am eternally grateful for the traditional medical training I had in medical school and residency: it afforded me the opportunity of having a wonderful career as a surgeon. However, what I have learned in these last few years has supplanted that education with something more profound and deeper. As a Christian, I believe what the Bible says in the Book of Proverbs that we are “fearfully and wonderfully made”. Yes we are indeed. Created to heal. Living a healthy life (which I did NOT for much of my life) and caring for the vessel we have been given in which to live. What I hope to do with this Substack is share what I have learned in manageable bites and from the standpoint of how all of it has effected change (and still is) in me.

Until next time: Press On!!

After four years of college (BA in History), one year of working toward a masters in History, two years of the Physician Assistant Program, one year of working as a PA in pediatric cardiac surgery, and four years of Medical School - all at the University of Florida, I entered a five year surgical residency at Orlando Regional Medical Center (now Orlando Health), then started my career in General Surgery in Daytona Beach, Florida. I am grateful for the extensive training I received, both in PA School and the College of Medicine. What I learned there and in my residency taught me how to be a doctor and how to think logically through diagnostic problems and how to take really good care of the sickest patients. It also gave me an absolutely grand overview of how effective American acute care medicine is — we are the BEST in the world at acute care medicine; I’m proud to have been part of the whole paradigm.

And after a whirlwind 36 years and 6 months in practice, I retired from that career.

I loved every day of my life during all those years of training and practice (not necessarily all of each day, but I never woke up in the morning and didn’t want to go to work). If you had asked me two years ago when I might retire as I approached birthday number 70, I would have said ‘maybe another 5-6 years’. I still had my skills (according to the people that watch such things), and I was loving the ‘job’ of taking care of patients. But then a funny thing happened; well, several things happened.

In 2017, I was diagnosed with ‘pre-diabetes’ and placed on Metformin; I developed hypertension and was placed on Lisinopril; I was also place on Prilosec and a statin. Then, in 2018, my condition worsened and I became a full blown diabetic, even with a maximum dose of Metformin. I finally figured out that I had to do something different. Looking around for an answer, I found a book by Dr. Jason Fung - The Diabetes Code (you can find him on Substack (Dr. Fung’s Newsletter) as well as X and YouTube). The book changed my life as I changed how I lived; 9 months later, my Hemoglobin A1C (a three-month look at average glucose levels) went from 7.7 to 5.9 ) technically pre-diabetic) without any Metformin. It wasn’t complete, but I was pretty far down the path of reversing my Diabetes, and my blood pressure med was cut in half as well.

Next came 2020. I was, to paraphrase Bones McCoy, a simple General Surgeon. But I was completely confused by what I heard coming out of organized medicine at the beginning and continuing through the pandemic years of 2020 and 2021 (although if people are still testing for Covid, even after 5 years, then those people are STILL in the pandemic mindset). Living in Florida was a godsend and I managed to take myself out of the pandemic by mid-April 2020. By that I mean that I stopped wearing a mask (which only lasted for about 2 weeks with me before I stopped running with the fallacy being promoted). We (Medicine) had known for years that wearing a mask during flu season was not effective in keeping health care workers in hospitals from contracting the flu (multiple studies). We knew several other things as well - as my own and two of my best friends (Family Medicine docs) found yet again as we dared to ‘do our own research’:

We knew that the virus doesn’t propagate well outdoors due to ventilation (even the CDC concluded, according to their website in 2020 that you would have to be within a foot or two of someone actively shedding viral particles for 15-20 minutes before you were likely to become infected yourself.

We knew that UV light (particularly the UV-C in sunlight) inactivates the virus

We knew that social distancing inside is not possible for protection against a virus (confirmed in a study from MIT in late 2020) and further confirmed by Dr. Fauci himself in the last year or so when he confessed that the distance was ‘just made up’.

We knew that hydroxychloroquine was effective in reducing the viral load of cells as per a study we found from the NIH in PubMed - an article written in 2005 regarding the use of that med with Sars-CoV 1. Wait. What? Dr. Zelenko who had a protocol based on that and a Z pack and Zinc was ostracized for using it in NYC. But now it was useless?

We knew other meds might be useful as early treatment as well (Ivermectin was getting some reviews in some places, particularly India and the tropics where it’s in common use). Also, a study from Stanford in 2020-21 showed that Fluvoxamine (an older SSRI) is also effective.

We knew that it was CRAZY to not try to treat someone who was getting sicker

We knew that lockdowns wouldn’t be effective (see 1918) and that masking school children was ridiculous (it was clear by mid-2020 that young people were not terribly affected by the virus but that older folks and the morbidly obese were at risk)

We knew that if people had a normal to high Vitamin D level they would likely not be as sick.

We knew a lot, but we were small voices in a small community. Larger voices got shunned, de-platformed, and de-frocked. But the thing was, for the first time in my life, I saw organized medicine do things, say things, promote things that made NO sense to me or many others in my circle of surgeons and family docs. For the life of me, I could NOT make any sense of any of it at all. It wasn’t until I read an essay on Substack by Dr. Robert Malone (Who is Robert Malone?). I highly recommend you go back and read it if you hadn’t seen it: Ontological Shock. The concept that you wake up one morning and everything you believed was true is suddenly NOT true.

Then, in the middle of all that, I had an increase in my PSA (prostate specific antigen), an MRI scan that showed an area suspicious for cancer, and a biopsy in May 2021 that showed I had a very high grade (Gleason 9) prostate cancer. I elected to have surgery after talking with my friends, the Urologist and Oncologists as well as doing a deep dive into the medical literature. The surgery went well; the tumor was completely removed with the prostate; the margins were free of tumor and 10 lymph nodes from my pelvis were negative for cancer. Hooray! I was offered the concept of hormone therapy, but it wasn’t pushed very hard and I rejected it without much thought.

I was fine until 18 months later when my PSA went up a little, then three months later to a slightly higher level. A newer PET scan (PSMA) showed I had cancer in four lymph nodes in my pelvis and after again searching the literature, talking with two medical oncologists and three radiation oncologists, I decided to undergo 6 months of ‘androgen deprivation therapy’ which takes your testosterone down to zero and hopefully stops the growth of cancer. Actually, all the recommendations were to have full pelvic radiation (about 6-7 weeks duration) as well as two years of ADT. I didn’t want that at all and opted for the six months of hormone therapy. My PSA returned to undetectable, but as I got the first injection, I started taking four supplements that had been shown to be good at treating prostate (as well as breast) cancer.

Part Two coming soon.

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As I said, I have been in surgical practice for 35 years (as of July 2024). In that time I have seen more than 75,000 patients in my office and have operated on more than 16,000 patients; I have performed elective surgeries as well as emergent procedures, and was also a trauma surgeon for over 25 years. Over time, I have developed a keen interest in patient education and I believe one of my strengths as a physician is my ability to communicate with people of differing backgrounds about their disease process and what needs to be done (as well as the alternatives in therapies).

With my own experience of having developed (and now curing) Type 2 Diabetes as well as having been diagnosed with a high grade (Gleason 9) prostate cancer, I can speak with more knowledge now about overall health and alternative therapies. My belief system now includes my background as an Allopathic physician (trained in the standard manner of all western physicians through medical school and residency), but has also expanded to include a growing knowledge of naturopathic principles which modern medicine has largely chosen to turn a blind eye to due to the fact that there is usually no large amount of money involved (at least compared to standard pharmaceutical remedies).

I have noted a few people who have followed me (I remain unsure as to why at this point, but am grateful for the start!). If my thoughts as we go forward spark interest — and even better — conversation, then I would love to have that interaction, so if you see this, pass it on, and let’s get started! I intend to begin by passing on some of what I have learned over the last few years.

Later this week, I will more fully sketch out some of the topics I’d like to go through.

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