Current Cancer Treatments Modalities, Including Targeted Drugs and Immunotherapy

 

Colin

Like to welcome Dr Ida Wongto today's conversation and just introduce her for the listeners here. She is an associate professor of medicine at the University Of California San Diego she has practiced oncology and Hebrew College for 8 years so welcome Ida thanks for.

 

Ida Wong

Thank you for having me sure. Yeah, no I'm a um ah Sand diegan born and raised and will I decided never leave here. But I you know.

 

Colin

Being with us. Can you tell us about your career path.

 

Ida Wong

Grew up here and then went to u csv undergrad and that's where I majored in biochemistry and biology and I guess I was interested in medical school but didn't feel quite ready to work so or go to medical school or continue school. So I worked in research institute here. And San Diego which was um, a great experience to work in the lab made me realize I didn't want to be in the lab but had some great bosses there that kind of you know, urged me they're both physicians and urged me to go to medical school and so um. That was my brief jaunt outside of San Diego and I fell in love on the bus ride over across park avenue in New York City and decided to go to Cornell there for medical school and lived up in the Upreats East side for 4 years and went to medical school. It was a great experience to see how the other side of the country lived but came right back to San Diego boomerang right back and came into um u cst or internal medicine here back in sango to be with my family I went to ucsd residency and I did a chief residency here. But for internal medicine is an extra year and then I continued on to use Csd Hematology oncology fellowship and stayed on so I work my all my clinical time is at the San Diego Va Hospital in the hoya but I am I do research on the ucsd side and also work in the medical education with the medical students internal medicine residents and the fellowship there I'm actually the the the. Associate fellowship director for the fellowship and so I have been at the va and use Csd for None ars now and time seems to have flown by and that's where I am at this moment and love my job.

 

Colin

What made you want to become an oncologist.

 

Ida Wong

Well so that's a ah more long story of how I got there. But um I two days before Thanksgiving when I was 16 I was diagnosed with acute myeloid leukemia and that is is really I think changed the course of. Not only my life for me and my family but also just I think my career just remember you know these vivid spots in my memory even though it's now a few decades since then but being taken out of my class and. Pretty athletic and I was getting these headaches and I was sleeping in class and so my mom took me to the doctor and and from there I was hospitalized and bonema biopsy later diagnosed with eml which is not common in that age group and. Um, things moved really fast and ah you know although I received chemotherapy my the cure really is a transplant and I was very very fortunate that my sister was a full match and we had ah I had a stem cell transplant up and. L a less than four months after my diagnosis. Um, and it's just funny because I think 16 is a very interesting and funny age to be in. You're not a young kid but you're not an an adult so I remember these memories of sitting in the pediatric oncologist. Office in San Diego and these like small toddler chairs and yet not feeling like I was fitting in and then on the transplant side I was really the youngest by decades amongst all the adults and so it's ah it's a funny age but I just remember a team of people. Nurses social workers physicians who are just all really a family to us and it it I think the transplant doctor just because you spend the most time with them kind of the biggest impression they made the biggest impression on me and I don't think it was a. Conscious effort to go into medicine I think in school I always liked math and science better than writing and um I mean even in college I used to envy my roommate who would write a None page essay in like two days while I agonized for weeks yet. I loved you know math and calculus so I think that was. Maybe already kind of the writing on the wall but sort of as I and I even tried a lab as I said I wasn't quite ready to commit to anything and didn't feel like lab was my thing but I think.

 

Ida Wong

After some soul searching I put my efforts into medical school because I really wanted in some way to to really emulate what my physicians were to me and give back to a community that kind of gave me everything and including my life but kind of ah a different. Personality even after um and I tried to like everything from surgery to pediatrics but it didn't fit like internal medicine and and eventually hematology I Love Hematology. It's like a huge big puzzle and oncology that. Just really get to be a part of somebody's life during this very challenging time which I think sounds scary to a lot of people but you really become part of their family just like my physicians were part of mine and so that it really shaped who I am and I think it it shaped. Um, it continues to shape how I treat my patients and how I have relationships with my patients and I know it's very cliche but I would say my my diagnosis and my treatment really shaped my life and changed my life and I think it was meant to be looking Back. Feels like it was you know a it was supposed to be this way and I think that's really the the long winded story to say of why became an oncologist but I think it really? Um. Makes me love what I do every day.

 

Dustin

Seems like quite the journey to becoming an oncologist and how you came to fall into hematology specifically. Um, how has your practice been affected by the pandemic.

 

Ida Wong

Yeah, no, the pandemic was also just similarly where you look back in time and you know when I have these snippets of memories of you know, just. Important times in your life and you can remember sitting around the table with all your colleagues and saying how are we going to manage these patients and try to give optimal care during this very crazy time and I think it really made us think outside of the box. Um, and. Oncology is very I think unique I'm not saying different from all others but in some way we never went fully telehealth. Um, you know a lot of medicine was changed over to um. Either telephone calls or video calls but we never one ah hundred percent went that way just because patients had to come into the hospital get their infusion center treatments and so a good percentage of patients were being seen in person and and how do we manage that with you know as little contact with nursing. Um, so you just minimize the touch points as they come in and I think that was a very it took a lot of communication between the hospital the nursing our physicians to really say what the best plan was so there is a lot of challenges and I work at the va which is a um. Older population for the most part and I think telehealth for those who are not that tech savvy and I am not tech savvy I can I can barely get the Zoom thing working without unmuting myself on most days but um to try to get our patients to do that was really. Ah, real challenge and so a lot of our our telehealth was done via the telephone which which were was hard. You know those were hard of hearing um or you know, relied on kind of a closer contact reading lips. Um. And we had a lot of head and neck cancers who had trouble speaking just because of Dysphagia um, it was ah a real challenge for all of us to try to provide optimal care during this time and even I think things that were really challenging were also trying to think of what we could manage as an outpatient. What we had to bring patients in for and then I even remember having this patient with acute renal failure because he just couldn't take that much intake because of his head and neck cancer and and being denied from the emergency room as a way to admit this person because.

 

Ida Wong

Um, they were so impacted with covid patients and how do you treat these acute needs while the whole system is impacted and so we really had to think outside of the box and changing therapies that were mostly inpatient outpatient I think it made us realize we could do it. That we could. You know everything didn't have to be brought into a hospital or sometimes we switch over oral pills and chose a regimen that could be done outpatient I think it really made us. Look at the data rethink the data and and decide whether we could still safely. Do it. So it's I think for the most part for us has returned to some sort of quote unquote normal. We're seeing a majority of patients in person. Um, and the patients like it a lot better, but there are a good I think it made us recognize that we can do things via telehealth I think there's a lot of patients who drive from far away to come see us. Um, a good portion of our patients live down in Mexico or you know live between you know Arizona and here that make it really challenging to drive and so it made us realize we could do things via telehealth and and still be safe about it. So. I think it's still evolving I think there will not I personally think we'll never go back to None in person because I think we recognize that we can do a lot of things telehealth and in in talking to my colleagues who actually. Treat patients up in washington they kind of said that we've been doing this for a long time because they're they're in a bigger catch area where they're treating new people in Alaska via you know Washington and. But it's made us all kind of change in some way and be flexible I think that's the biggest thing to be flexible with our patients and so I think I think it's still being affected but a lot of that has really settled down a bit. But really was a big life-changing altering time for everybody and but I think it really showed us how we could really band together as a network and and from the hospital down to you know the the people seeing patients in clinic that we could.

 

Ida Wong

Kind of do this together if we kind of just came up with a good plan.

 

Dustin

It sounds like it was a really a hard time and that you were very adaptive throughout that process and everyone has been practicing flexibility during this time I think.

 

Ida Wong

Absolutely now it really required this back and forth push and give because even in our clinic space we were then told you know we they had such a large number of covid patients that they had to take some of our clinics. Space None and so it really really required us to be like okay now that we have only two-th thirds of our clinic space how you know how? how do we then shuffle our patients in and out of clinic and so it really required communication and flexibility and. I think really I think those times could really show you how well you know everyone could work together. So you know it's not to say it was all it was great. All the time. But I think you you recognize. You know you really have to sit down with your colleagues and say how can we make everything work with the limited resources that we have and yeah, um, while challenging I think we all need those sometimes those challenges say can can we do it. Can we be flexible with what we have and. I think it really tested us and there are some hard times and I think we were able to manage very effectively.

 

Colin

I Love that explanation and just ah insight into how your particular health care system pivoted into you know, dealing with the pandemic and and having. You know so many challenges with being able to treat your your population. You know I wanted to ask if you could tell me more about your your role at ucsd.

 

Ida Wong

Yeah.

 

Ida Wong

Absolutely yeah, no, um I am my main again. My main clinical duties are at the va which I think in itself lends itself to medical education. So and just to explain that. What. The va is kind of interconnected. It's even on u csd campus and it is essentially a trainee hospital so every subspecialty and every specialty from internal medicine or surgery have trainees in their in their clinics and the trainees include medical students include residents. And include fellow. So I think having that type of setup already lends itself to certain physicians who like working there just because you will always be working with trainees. But I've always had an interest in clinical education I think I was a little bit of the black sheep. Um, because hematology in Onngolia is actually very science based very clinical trial. Very translational and basic science. So I'd say majority of people who come in have some research background in in the sense that they either work in the lab or they run clinical trials or. That's their goal. So I I came a little bit with black sheep in the sense that I came in and said well I don't know if that's one ah hundred percent where my interest is I'm really interested in in being a clinical educator and. And so I started as a chief resident and so that you take an extra year and essentially that year you teach the residents. You know morning or report you run through cases. You do new conferences and essentially run with the team of internal medicine leadership the the medical education for internal medicine residents and so that I think was a great. Um. Stepping stone for me to say this is what kind of drives me you know and I could spend you know my interests at the end of the day was always trying to make new teaching material for the residents to either make the transitions easier or creating. Teaching cases that could help them understand whatever whatever topic we are discussing and I find I found myself loving that portion of it and so I had a great number of mentors at Ucsd That gave me the opportunity to leverage that and might leverage my interest and give me opportunities.

 

Ida Wong

To teach even as a trainee. So um I took that into fellowship and kind of continued to do didactic. You know, teaching cases with other medical students and residents and then when it became a faculty it kind of weaseled more opportunities. Um and kind of. Inserted myself in certain places and said can I help and that has led to leadership positions in the medical school residency and fellowship arena so in the medical school I.AhCo -direct a case with one of my mentors Aaron Reed we just finished the course the hematology course for the first year medical students and in the residency and kind of the core hematology oncology. Director of their Friday schools and so I work with the chief residents to kind of come up with their curriculum for their Friday school which is kind of dedicated Friday afternoons to teaching different topics and then ah now I think maybe it's ending my fourth year of fellowship um leadership as an associate program director and so I you know I think it's it's definitely a more challenging time I think pre covid we kind of were getting in our groove and then covid. Sort of hit and I think that we're seeing medical education and ah having to revamp a little bit or a lot of it just because we're having trainees who are either as medical students or residents have lived through covid and and as they try to adjust to telemedicine. Um, and also having years that were kind of chunked out of their training. We have a lot of interns now that literally for you know, a good you know number of months they were were sitting at home during covid and and not being taught and so I think. That has created more opportunities for us to kind of pivot and be flexible and learn how to adapt ourselves in this model. We used to interesting have all in in person teaching and our last medical school was our none um. Covid time teaching that we did a hybrid in person and otherwise recorded videos and I think we're we're we're learning the the pluses and minuses of of all of them and um I think that's what makes it fun. It's still.

 

Ida Wong

I still very much enjoy it and I think it requires that same idea of flexibility within that role to really say what? how can we educate the next generations looking forward and I think it's just fine because I think it keeps Mia Myos They always ask all sorts of questions that make me. Scratch my head and look into things a little bit more and how we can do things better or change things or keep things the same. So it's it's been a real um I think a good fit for me at ucsd.

 

Colin

And you know I was really ah curious as to how maybe the cancer field or oncology has has changed over the course of your career I've I've heard how there's been. You know very needed then um. Wow Blocking Ah my thoughts here just a response to the the covid but I'm curious if you could speak to maybe other things that have been advanced during your career in the field.

 

Ida Wong

Oh.

 

Ida Wong

Yeah, yeah, no I mean I think in some way covid has also regenerated that idea of you know I think making it to the to the to everyone in the world that what? what? you know the needs of clinical trials. Because on oncology that's sort of our thing is we're always trying to look for new drugs. So I think covid really pushed forward like that. Um. That's why I was amazed by the vaccines and how quickly they're able to accrue so many people and just the manpower that is required to do that was just awe-inspiring and I think in many ways kind of really energize people to to really think about clinical trials as an as an option. For new drugs and things like that. but but necology has absolutely changed in the last Decade I tell fellows all the time. But I I'm having to learn things with you because. There are a lot of drugs that were not approved or just being approved when I ended fellowship and to use these drugs you know sometimes you turn to your your you're attending or your person that you're staffing with and as a trainee you you hope that they have this years and decades worth of you know. Experience with these drugs and when these drugs are being approved and kind of in real time we're kind of learning all together and that's really been. Um, you know the fun part of oncology but also the challenging thing as an oncologist but um. The last decade there has been a boom in in such drugs including targeted drugs. So non-chemotherapy drugs that kind of target a particular pathway and including oral therapies that are better options for older patients. Um, immunotherapy which um, you know, got approved um a little over the none one got approved a little bit over less than a decade ago has really revolutionized our world and and the newest sort of. Immune therapy car t which has come along which is ah is just a fascinating way to to think about and treat cancer and so just to the immunotherapy which I think really has been the biggest change. Um and.

 

Ida Wong

You know prior to to Tammunotherapy. We really only had chemotherapy and I always when I teach trainees I say who cures let's say solid tumors and it's honestly not an oncologist. It's a surgeon. It's a surgical oncologist who goes and cuts out the tumor and um I think it's. Mistaken that we can come in with our our drugs and be able to um to cure people and and we can really only do that in in liquid tumors like lymphoma or leukemia and um and chemotherapy doesn't cure metastatic solid tumors. It just really prevents Dna synthesis and. Even if there's one celllo leftover it can it can grow and so we don't really cure anyone with our chemotherapy and then along came immunotherapy and it was really not a new concept. It had been around for centuries and um, you know even I remember being taught in a lecture. They said you know that. People who are thinking outside of the box even try to use small doses of infection or to infect someone with a bacterial infection to amount an immune response and that showed um and ah it slowed tumor growth. Um, obviously it fell out of favor because you know this is kind of done in like I think the early nineteen hundreds and people actually got infected which you kind of don't want either. So um, and it ah you know I think people were it was a little too out of the box at that time but it kind of made a resur I mean it still was. Done in the in the basic science arena in test tubes or with animals that showed that animals could be immunized against remove tumor cells. So in some way you could use the immune system to try to control tumors. And then this kind of had a resurgence in the 1980 s and we had a ah interferon alpha and I l 2 which are essentially cytokines that are made by the immune system but we. Kind of used it to treat solid tumor and there was some response there were Fda proved and but they made patients really sick. Um, essentially I called it because in my training we actually used it I call it giving them essentially the biggest you know infection response. Um, you get low blood pressure fevers delirium renal failure I mean it was a full body illness and while I know it was terrible I mean I remember like just being fearful when a patient would be admitted for this because like oh my gosh I'm going to make them feel miserable.

 

Colin

Um, sounds fun.

 

Ida Wong

It was terrible and they in um, but you know it would slow tumor growth and so but it was not fun and um so I would say wasn't. You know I remember 1 of our attendings too at the time said you know immune therapy is goingnna be the wave of a future and at that time I'll too and inter interfereing alpha were like the only drugs that were approved and I think all of us in that room are like okay buddy I don't think so but um, you. Along came these checkpoint inhibitors which are a different way of the body the immune system and essentially they are immune checkpoints and the it's sort of the body's own way of protecting healthy cells but also killing cells that are. Not supposed to be there right? Our body all the time are making mutant cells and their our immune system goes oh wait. That's not normal and then let's get rid of those or hey that's that's normal. So don't don't do that so I call it this like bracing gas pedal of our our. Our immune system to try to either save the ones that are healthy and try to kill the ones that are and activate the immune system and kill the ones that aren't and they're using this this system these new checkpoint inhibitors to essentially kill be a treatment for for cancer. And so what I call is these antibodies that essentially block the or so essentially their antibodies. But it's almost like cutting the brakes cutting the brakes to the immune system. So it allows the immune system to go go go and this has revolutionized our. Ability to treat cancer and so in I forget the year I want to say none? Um, the first of these checkpoint inhibitors were approved in melanoma and um. Now if you look at melanoma with these checkpoint inhibitors where patient survival was so poor. A recent study came out and said that in those advanced melanomas the average median survival of these metastack patients is 5 years which is. Crazy I know it doesn't seem like huge to you guys. But in our world of metastatic non-curable disease that is amazing and we're we're getting these patients who have very long-term a mission whereas chemotherapy never did anything long term essentially because it.

 

Ida Wong

Eventually the tumors got really smart and would find ways to evade the the chemotherapy the immune system it's it's a little if you just continue to activate the immune system. There's always going to be the gas on in some way, you're going to have some blank of effect on cells. Especially. Specifically tumor cells if they have a response so these guys are having long-term emmisions in one of my patients is a non-s small cell cancer and the average survival is about a year and I just saw him in clinic with a resident I'm like and here he is seven years later

 

Colin

Awesome.

 

Ida Wong

And he's alive. Yeah, and so it's just watching these patients and it's funny because the whole that whole patient interaction with him and the resident was not talking as cancer because his cancer had complete remission now for years was now that he's like 82 he had. Worsening dementia and so I'm like our whole appointment was really talking about totally non-cancer stuff because his cancer was so well-contro and metastatic he had. He had essentially um, blown through all chemotherapy options and he went on a clinical trial at the time at ucsd for the none immunotherapy and then once they got approved he came back to the v and he's continued on that drug and so I'd be thinking you see these now. They are not all home runs but you're seeing these patients who will have this very long-term. Ah, remission dare I say cure but remission for long term and so I think immunotherapy in that way has really changed our ability to treat chemotherapy used to be really hard to take if you were older and couldn't tolerate the side effects. Um, and the bone marrow toxicities but immunotherapy typically now they do have a good good. You know on on a whole maybe None of severe immune adverse effects but we have eighty year old and ninety year olds on immunotherapy with just a little bit of fatigue. So you're able to. Offer treatment options to a larger patient population that weren't offered that before and so that I think just is so amazing and such a story to tell. Um. You know and that I think it's just the beginning of how we manipulate the immune system and I think oncology in that way has now we're dealing with ah sometimes a chronic disease but also oral therapies that allow us to treat younger and younger I mean you're not younger, but more patients that wouldn't typically treat. Wouldn't be able to treat with them with chemotherapy.

 

Colin

You know Ida as I was listening to talk about Aminotherapy and I had this ah visual image of a bouncr at a nightclub and I'm like you know you called them checkpoint inhibitors I'm pretty sure balancers need.

 

Ida Wong

Ah. Ah, yes, yes, but it's a good Way. We know we always need an analogy because when we're telling our patients. How and I tend to use the gas pedal and the brakes and.

 

Colin

That is their title that they are now checkpoint inhibitors for the nightclub. Ah but might be a silly way. Yeah.

 

Ida Wong

But like we're always needing a way to tell our patients and when we tell them about the drug and consent them for the drug and maybe I'll use that um I'll use the ah bouncer approach. But.

 

Colin

Um, I'm for it.

 

Ida Wong

Ah, yes, but it's it's certainly been fun because you feel like you're part of this ever changing field and it's fun creates more ideas of. For a person who's more so basic Science Translational Science minded to go back in the lab and ask these questions of you know how can we manipulate the immune system or more to really? Um. To find new novel treatments and I think that's the fun part about but as a clinician to be able to um to use these drugs and see the actual effect and have the quality of life maintained for these patients is just it's. Been so rewarding and I think it's been so rewarding to also see the excitement in in the trainees that come into clinic because sometimes the trainees always see the patient. They tend to do a lot inpatient and so all they see is like the bad effects of immune therapy because don't get me wrong. There are. Bad effects of immunotherapy if if they get None of those immune toxicities. But then they they're like oh why do we even do this and then they come into our clinic and we're like oh this is why because the other 98% of patients that you you know you don't get to see are kind of flipping along in clinic and doing. Doing quite well on immunotherapy so it's it's been really rewarding from all ends from a scientific side but also from a clinical side.

 

Dustin

So it sounds a little bit like chemo in a way because Chemo is not fun and it does have benefits. But then there are those like percentages like in immunothermmunology immunotherapy that also have like really adverse effects is there.

 

Ida Wong

Yeah.

 

Ida Wong

Okay.

 

Dustin

Is there any like long-term effects of immunology similar to chemotherapy.

 

Ida Wong

Yeah, it's a it's a there are so it's at the majority of patients roll out with a little bit of fatigue. Some people get ah you know as I when I tell patients. Majority is gonna say I feel a little bit of fatigued and they may or may not have to start some thyroid medication because Immuno Therapy can essentially by cutting the brakes you allow the Immune system to to go unchecked for a little bit and in hope that it you know kills the. Cancer but in some way can also start to inflame a lot of other Organs lung Colon skin. The most common is the thyroid. Um, and so people tend to have to go on some sort of thyroid replacement and and that's the majority of patients. Here's a little thyroid replacement. Um, you know a little bit of fatigue that doesn't affect their life. But there's that percentage of patients who get the terrible side effects that force us to hold the therapy and then have to actually stop the Immune system with some steroids. Um. And Plus or minus some other medications depending on the side effect and and those are the most challenging cases. Um most of it. You're able to reverse with some steroids high doses so steroids. But there is a there are a portion of patients who kind of have long-term.

 

Dustin

You know.

 

Ida Wong

Um, effects. Especially if you can in sort of that risk benefit. We have None patient who literally has almost. We've knocked out his pancreas. So he's now on insulin and it's a very rare side effect but he got it and then he also has a rheumatoid arthritis or inflammation of the joints and so he's on some you know anti-inflammatories like Mephottrexate just try to slow it down and this is just his long-term effect. Um, and we even tried stopping stuff. This is immunotherapy and that honestly didn't help and so sometimes you see I've seen chronic fatigue too with with these drugs that. There's just a subset of population that just the because the the drug's been in there and it stimulated the immune system. The immune system is still going and there's not ah in this subset of patients a good way to so. To stop. It. Minus putting them on high dose steroids all the time which we don't like and so yes, there's a there's a subset. What's interesting is some of this subset actually has because immune system keeps going control of their disease. Um, and it's this. Tradeoff right? and this one bladder cancer patient I have um, you know has had no evidence of disease for years but he lives with kind of chronic joint problems and chronic fatigue and it's sort of that tradeoff that. And chemotherapy. You know you were metastatic and chemotherapy would have never had this long-term effect but he's living with kind of chronic symptoms. So it's I think it's a very challenge while we're very rewarding can be very challenging. Challenging for quality of life for a subset of patients.

 

Dustin

So it sounds like it kind of like boosts the Immune system to like a super level for a period of time because you said it removes those limits. Um and ah on on this note I haven't a different question for you. Ah.

 

Ida Wong

Um, ahaha.

 

Ida Wong

1

 

Dustin

How do you incorporate a whole person approach to treatment.

 

Ida Wong

Yeah, no, that's I I think a ah great question from you know from the get go. We even try to incorporate. So. During our new patient appointments whether we're going to start chemotherapy immunotherapy or so or targeted therapy and oral therapy because I think you don't know what's going to happen and I always say to my patients I wish I had a crystal ball to say what's going to happen in the future. Um, in terms of side effects whether you're going be None person that breezes through I mean at a 80 something year old patient that brees through um, you know treat with chemotherapy and had none side effects and you know a 40 year old person that had. You know, major side effects with the exact same chemotherapy at the exact same dosing. It's so hard to anticipate all all the potential side effects of any treatment options that you offer and so I think um I think it takes a ah. Family in a village of people to to treat the patient as ah as a whole and I think some people include from a social worker to a dietician or a nutritionist for oncology. We have case managers and we have infusion center nurses. Um, we have psychologists and psychiatrists supportive care via palliative care and and that's all in addition to you know the physician seeing the patient and so and I also believe that the body is just really one aspect of care. But. The mind is another and that mind includes what you put into your body and and so as ah as a oncologist we only have unfortunately you know I wish things were different but only so much time we have per patient in our schedule and. And to try to fit all these aspects of you know their financial needs to their home needs to their diet needs to their their sort of where their mindset is really unfortunately challenging for us to be able to to do it all in that time. Period of time and give them the patient what they need and so I think from the get go are are when we see the patient we. We actually have them meet with our case manager and if there's any specific needs we have that.

 

Ida Wong

Our case, manager kind of help them kind of fit into the right? um family member if you want to call it that so from the nutritionist to the social worker we try to give them all that. Those options even our psychologists the options from the get go when they first meet them and so on our checkout sheet. We'll even have everyone listed there from them case manager to a social worker to the nutritionist we don't have our behavioral health. Um, ah. Or psychologist number on there but we do you know verbally offer it to them and so I think you know thinking about things as a whole even though it's very overwhelming on that none visit, we tend to then kind of reinforce as we go along about what what the the patient needs because. Think the treatment is just None aspect of it and there's so much more to what the patient needs and so I'm all about the whole person approach and I think yeah, um. While overwhelming if you are able to do in small pieces and you build that rapport with the patients then they start to trust other people and allow those family members to really support them. So I think it really honestly takes a village and some of our and the patients really I think. Like that because they they feel lost sometimes and if they they find that there's people to catch them in different arenas I think what's the most challenging is really just the the logistics of China who do I reach for this and and where do I go to. But once they kind of get the hang of it and. Along with our case managers who are kind of double as nurse navigators. They're really, they help them navigate through this portion and once they kind of get settled it. It really is it. It should be a ah whole person approach.

 

Dustin

Yeah, it sounds like there's ah a just a large team that's like providing care that oncologists is just you know as an oncologist, you're a part of like a large collaborative team that's providing care to these patients. Um.

 

Ida Wong

Absolutely.

 

Dustin

As an oncologist I just wanted to ask? Ah what you know since I'm a nutritionist what in your experience are kind of questions that maybe patients ask you and what's like kind of like the protocol for an oncologist and as far as sharing about nutrition.

 

Ida Wong

Absolutely no I mean I think that's a great question and we get this question a lot I'd say if we were asked about I think the most common thing we're asked about is diet and what should I eat and so this is just my opinion and my approach to my patients. Um. Is that in oncology you know I think Also for diet there is some. It's something patients can also control and so I think that gives them the control back with someone helping them to make choices that. Um, will fit their needs. But I think patients are always asking me. What should I eat and I think family members are also asking because they like to cook for them and they like to you know we you know the same way. I Cook went to to make my family happy I Think that's what family members do to people who are are not feeling well and so um, yeah, that comfort thing and and so I think it really does give patients back that control and and I think I oftentimes I think.

 

Colin

Have that comfort food.

 

Ida Wong

None common the most common thing is asked about the diet The other thing is that the nutropenic diet I would say also from an inpatient side I get asked a lot about what that means and maybe I'll answer that question none and then answer the none one is the nutropenic diet I think is is. It's never been by any. You know, scientific way proven to be um, you know I don't know beneficial is the right word but does it make patients sicker to to adhere or does it make patients safer to adhere to the nuuttropenic dow which is essentially when patients are. Very low white counts to not eat. You know, kind of foods that potentially can introduce bacteria and I find it a little bit challenging and I would say my practice now is different than it was ten years ago when I said absolutely not. You shouldn't eat all that stuff. Um. I think I always say you know work with a nutritionist but my big thing is if you are on a nutropenic diet because your counts are low to think about even if you do want fresh things because it's really hard to then start limiting patients on their diet when they're really not hungry and they want. Want certain things you want calories in is that I say hey you know I would if you want you know our our goal is not to introduce foods that potentially are not washed clean and still have bacteria on the outside or the inside like raw fish or raw meat. If I still tell patients not to eat raw fish or raw meat because that's unfortunately you can't you can't fix that portion of it. But I think like raw vegetables and raw foods I I tell patients if you want to do that and that's really what you're craving do it at home where you're not going. Don't bite from like you know the grocery store. Um, where you don't know who washed it but at home you have a person who's going to be very diligent about washing that you know spinach or those strawberries um very carefully and so I tend to maybe be a little more lenient just because I don't always have patients who. Limiting their diet should be. You know, living their diet is even harder. Um, but I think that's changed my my voice on that has changed over the years just to to make sure patients still have some options in terms of the diet itself I I always lean on the nutritionist.

 

Dustin

E.

 

Ida Wong

Um, for supplements because oftentimes patients don't want to eat and they but what the None thing I say over and over what's been proven in any field of of oncology whether that's leukemia bladder cancer. You know, um. Lung cancer is that we need to keep the weight stable weight loss is absolutely a poor prognostic sign and so to really be cognizant of that very early and so that's where I absolutely then.

 

Dustin

M.

 

Ida Wong

Use My my nutritionist Dietician to say you know our goals are to keep the weight stable. However, that is to work it out with the patient to come up with something that is very tailored to them whether that's at additional supplements or or not or finding you know higher calorie. Um, foods that are not quite as you know feeling like you have to eat ah a full meal. So Unfortunately I don't you know it. It takes a lot of time and also expertise that I don't feel like I always have and so I always like from the get-go will refer pretty early and even.

 

Dustin

E.

 

Ida Wong

Cancer patients who are cured I'd say I will tell you patients have come back and said boy that nutritionist was the best and like four years later I wish someone had told me that um, one patient who had um. Colon cancer but he also has ah a familial polyp syndrome that required him to remove his entire colon and so he had changes in bowels all the time and we couldn't quite. You know Ah my as a doctor I'm always like okay, let's try medication. And he's like the one person who made this change in my life was the nutritionist who's like yeah dude, you don't have a colon so we need to change your diet and he's like it was a miracle and now I can kind of feel like I can have a life where I'm not relying on a bathroom and so I'd say even from our from our cure to our mostly you know treatment patients. It's a it's a it's a big part of our family.

 

Dustin

Yeah, that's really, ah, that's awesome that you've been able to like lean on the Dietician more and in providing that and and the mallinenutrition piece is really big with cancer patients because you know you're just not hungry during like the chemo.

 

Ida Wong

Um, yeah, and it's really it's and I suppose this is where my my history I have much more empathy for it because I remember distinctly when I was sick I'm like if there was a. Pill that had two thousand calories in it I would take it I mean right? I mean do you remember like if I just if they had a pill that could give me all the calories I'll take it and like you would never in your ever in your life. You know people would stare at you if you were crazy because food is such a.

 

Dustin

Um, yeah, yeah.

 

Ida Wong

You know an important part of our lives that make you know that little receptor in our brain say you know I'm happy is just but you know during treatment for whatever reason it's just that part gets shut off and and so it's really challenging to um. I Think as also as family members too to understand that portion to be like I don't know why he's just not eating and um and and so it's a huge part and I think having you know that sort of empathy factor is. Yeah, makes makes it a little bit more understandable for me, but this is where I kind of lean on other people to say. Maybe there are ways you know outside of our typical way of thinking to to get nutrition in.

 

Colin

Yeah I Like how you spoke to the whole person approach is as needing a village my mind went to like what does that make us the Village Village people. I mean there's a you know a cop a construction worker. You know there's There's all these. Ah. Jacks of trade so to speak. Um, that are to maybe speak to that. Ah, usefulness, maybe that's what the village people were trying to then convey there. Not just now promoting the Y Ca ah.

 

Ida Wong

Since this is.

 

Ida Wong

Ah, maybe ah.

 

Colin

But I you know I was gonna ask if ah there was any other aspects of your personal cancer history that has changed your approach I think you've spoken to quite a bit of that but I didnt wanted to maybe circle back to that and see if there was anything you want.

 

Ida Wong

Yeah I mean to I think to Dustin's question on the nutrition I think I'm definitely much more empathetic and and knowledgeable and I'll even say that. Um.

 

Colin

Wanted to add.

 

Ida Wong

I'll even explain it to family members like you know it's really hard to understand um the idea of not being hungry but it's a real phenomenon and I think is really just to take that small. Bit of time to tell family members. It's not you know that he doesn't want to he or she doesn't want to but it's really a part of the disease and so I think it's made me take those moments in the clinic when we're. Kind of on a one track agenda to try to talk about treatment options is to really acknowledge I think the hardship on the patient. Um, really acknowledge the hardship on the caretaker because I think that is also got us different set of challenges and it's it. It you know? Um, ah recently had a patient who really didn't want to take supplements and I don't usually share but I you know I said you know and I when I was None through you know my supplements down the. Toilet um, in was only caught when you know my mom was cleaning and saw pink flex flecks of insure in the toilet. Um that she recognized I was washing it down the toilet but recognizing like I get it. We do things and we we um. Want that control back in our life. You know, but explaining what the goals are in trying to I think I'm much more shared decision making because I think there are times where we as an oncologist can come in and say this is our treatment plan and because the data. Shows that and so we're going with that that is not tends to not be my um, my my only I have to take the whole person into account of you know what is there? What? what are their goals. Um, you know what kind of social situation. Do they have is there an option that could be more tolerable for them given their goals. Um, obviously I still want to follow what is. Standard and what will provide hopefully the longest life but there are plenty of times of patients who say I understand it's going to be longer life. But um, but coming back and forth to a hospital is not my plan and then we have to pivot and into.

 

Ida Wong

To Listen to the patients because as long as and I and my kind of thing is as long as I've educated you on what would be typical standard and why we're pivoting and you know to fit your goals I think that shared decision making I think is much. Has changed how I I mean my history has changed how I practice mostly because I think patients want to be heard um and but I think it I think it allows me a different empathy. Not to say every other person who doesn't have this history. There isn't but I think it's definitely shaped how I approach the patient differently than than what I think then the literature says which is sometimes a very this data is better than this data and so this one is. Is what we should go with um because I do think quality of life matters immensely and what their goals are.

 

Colin

So well Ida I just wanted to thank you for sharing your your expertise and I also wanted to share that we had been connected by our physicians you know through our our shared healthcare system treatment back. Gosh a couple years ago you know with with the you know the thought that we were kind of in that middle like you were describing and I was I was 19 when I was diagnosed um and um.

 

Ida Wong

Yeah, a couple years ago ah

 

Ida Wong

Ah, here.

 

Colin

That's kind of how our path crossed and I think I wanted to just share that that it's just been really awesome to see your career path and see how you've ah then been able to then share your your. Ah. Your medical knowledge with us and have this conversation.

 

Ida Wong

Yeah, no I mean I think wow yeah, it's so rewarding to see um you know the None of you um, have this history and. In both in both your cases also shaped what you did and how you approach um you know your practice and I think it's um I think history. Um shapes who you are and and. And the people that you meet and I just really commend the both of you guys as well for for wanting to to share your history and what the wonderful things you're doing through this podcast to to share with others on a totally different platform. Um, I you know I think people but you scratch the surface everyone has something as part of their history that has defined them and and how we go forward using that you know, whatever history that is to define them to do. Whatever good in the world and and I share that same sentiment with Youtube and I just think it's amazing that we get to share this and now with others and and hope that in some way. You know, even at None and for me 16 you know inspire each other to persevere and you know go on to have a healthy career and a healthy family. However, that's made up so it's been It's been rewarding for me as well.

 

Colin

Thank you very much for your time and ah like I said we really do appreciate being able to then see your career trajectory and and your growth. So.

 

Ida Wong

Thank you.

 

Colin

We will end there.