Healthcare Unfiltered
Healthcare Unfiltered is an honest, raw, timely podcast tackling any and all topics in healthcare that affect stakeholders. Dr. Chadi Nabhan uses his dynamic conversational skills to challenge his guests to address controversial and important topics. He also brings on world renowned experts to discuss clinical advances in medicine.
Healthcare Unfiltered
Episode 275: PAVING the Path After Breast Cancer With Amy Comander
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Chadi sits down with Amy Comander, MD, a breast cancer medical oncologist at Mass General Brigham Cancer Institute and author of “Paving Your Path Through Breast Cancer and Beyond,” to discuss how patients can take control of their health and quality of life after a breast cancer diagnosis. She shares the inspiration behind her book and offers a practical, lifestyle medicine–focused roadmap—covering nutrition, physical activity, sleep, stress management, and social connection—along with her “PAVING” framework for sustainable change. The conversation also explores her perspectives on popular diets, the psychological aspects of survivorship, and the key takeaways she hopes patients and caregivers carry with them beyond treatment.
View more about her book.
https://healthylearning.com/paving-your-path-through-breast-cancer-and-beyond/
Check out Chadi’s website for all Healthcare Unfiltered episodes and other content. https://www.chadinabhan.com/
Watch all Healthcare Unfiltered episodes on YouTube. https://www.youtube.com/channel/UCjiJPTpIJdIiukcq0UaMFsA
It's Shadi Nabhan. It's Healthcare Unfiltered. Folks, welcome to the show. I appreciate you tuning in. And today's podcast is with Dr. Amy Commander, a physician and a breast medical oncologist at Massachusetts General Hospital, who recently came with a book, Paving Your Path Through Breast Cancer and Beyond. This book takes patients, caregivers, and survivors through the path to have better quality of life. What do they do after a breast cancer diagnosis? It's an amazing book that has lots of evidence into what patients with breast cancer could do from nutrition, physical activity, sleep, stress management, social connectedness, and so on. So Amy and her co-author provide a guide, a practical guide for patients and caregivers to go through the process smoothly with the idea that this is going to improve their quality of life and more importantly, hopefully have a positive outcome overall from their disease. A great book, I highly recommend it, available everywhere. And I'm very grateful for Dr. Amy Commander, the one of the authors on this book, to join me on Healthcare Unfiltered. And folks, don't forget to check out the podcast on all other channels. You can subscribe to it, join the conversation, have a comment, have a review, talk to other people about this podcast episode and others. And you can watch all of the podcast episodes on YouTube channel, my YouTube channel, Shadi Nabhan and Healthcare Unfiltered. Without further ado, Dr. Amy Commander on her book with her co-authors Paving Your Path Through Breast Cancer and Beyond. Dr. Amy Commander, welcome to the show. It's your first time on Healthcare Unfiltered, and you promised me this not gonna be the last time, by the way.
SPEAKER_01Thank you for inviting me.
SPEAKER_00Well, congrats, first of all, on your book, um, Paving Your Path Through Breast Cancer and Beyond. And, you know, the focus of this podcast is going to be on the book and what you wrote, you and your co-authors. But I'd love to start just getting to know you a little bit more and get the listeners and viewers to know who you are and what you do.
SPEAKER_01Thank you again for the invitation. Honored to be here. So I'm Dr. Amy Commander. I'm a breast oncologist at the Mass General Brigham Cancer Institute and Harvard Medical School here in Boston, where it's still very cold right now. And I'm also director of the Lifestyle Medicine Program at the Mass General Brigham Cancer Institute. And so I'm happy to speak about that too.
SPEAKER_00So, what is the lifestyle program? Tell us uh a bit about what that means. People understand the breast cancer program, but what's the lifestyle program?
SPEAKER_01Right. So, this program, by the way, is a multidisciplinary team effort where we see patients with any type of cancer diagnosis and provide them with tools, evidence-based from lifestyle medicine to help them improve their health and well-being. And in many cases, we hope their outcome from their cancer, and we really focus on the six pillars of lifestyle medicine, which I'm happy to describe as well, if you would like me to. So, really focusing on the role of nutrition, physical activity, stress management, sleep, social connection, and avoidance of risky substances.
SPEAKER_00It's amazing because these are things that I can appreciate how they scale across all cancers, right? I mean, they're not really specific to any cancer. And I love the fact that you said um it's evidence-based. Uh because let's face it, sometimes some of these recommendations people criticize them, that they're really not evidence-based. I'll admit my answer usually certain things, I don't need evidence. I really don't need evidence to tell me that sleeping well is good. So, Amy, how do you reconcile this? Because you know, you can't have evidence for everything that you'd like to recommend to a patient.
SPEAKER_01Great point. But you know, certainly it does help to get, you know, us as medical oncologists to bring up these issues in clinic with our own patients when there's good data to support it. Just to use exercise as an example. You know, exercise is actually in the ASCO guidelines that we are all supposed to talk to our patients during active treatment and counsel them about the benefits of physical activity. And there's, of course, the specific guidelines which we can get into. But unfortunately, only a small portion of us are actually talking to our patients about this in clinic. And so the message isn't really getting out to our patients. And so this is an opportunity, you know, to work on. But I think having the research base and having this part of the guidelines does help motivate all of us to bring up these important issues with our patients.
SPEAKER_00Absolutely. So let's shift gears a little bit. Um, tell me what was there a moment, a catalyst event, something that happened that made you think, you know what, I want to write this book.
SPEAKER_01Well, it kind of started a little bit before that. So I can tell you, you know, as a breast oncologist, you know, which I've been doing now for many years, and I love my job, I think you would agree as well. We learn so much from our patients. Our patients are the ones who are asking the tough questions, and they're the ones that motivated us to do what we do. And so I just remember early on in my days as an attending physician, you know, my patients are completing their chemotherapy or their radiation, or they're trying to manage the side effects of tamoxifen or aromatase inhibitors. And they're asking me, what kind of exercise should I do? And is it safe to exercise? Gee, like everyone's giving me diet advice after cancer. Dr. Commander, what do you recommend? And they're asking me, you mentioned sleep earlier. I can't sleep. How do I improve my sleep habits? Very basic, fundamental questions that, you know, given the many years of medical training that we all go through, you would think we'd be very equipped to answer these questions. But I did not find that to be the case. I felt, wow, I didn't have a lot of nutrition education in my residency and fellowship, nor did I really know how to prescribe exercise to a patient or to really fix their sleep problems. And so I early on introduced to this field of lifestyle medicine through a conference here in Boston that was sponsored by Harvard Medical School and the Institute of Lifestyle Medicine. And I really loved attending that conference and learning from the presenters and realized that I really wanted to learn more about this field and integrate it with oncology care. And so that's what led to sort of getting into this and learning about it and starting a program for patients, which ultimately led to this book.
SPEAKER_00How long, first of all, did it take you, you and your co-authors, to write the book?
SPEAKER_01So shout out to my amazing co-authors, Drs. Beth Freedes and Dr. Michelle Tulfson. So I would say, well, this is actually our second book. We first wrote a book that was more general called Paving the Path to Wellness and really for anyone to read who would benefit from learning more about the tools of lifestyle medicine to improve their health. And I had started in 2019 this lifestyle medicine-based survivorship program for individuals with breast cancer after starting this collaboration with Dr. Frades. And early on, I realized, you know, it would be great to have a workbook for this program. So patients have something they can read and refer to. You know, our patient population is very motivated. They want to read, they want to do their homework, they want to see the data. And so that's sort of what inspired us to say, okay, we need to develop a book specifically for the breast cancer population. So that was, we started it honestly, probably in 2020 or 2021. This has been truly a labor of love, and I'm just so glad that we can now share it with the world.
SPEAKER_00So if I'm a patient and I'm picking up this book, first of all, what should I expect broadly? But what do you think that, you know, as I'm just flipping through it as a patient, what do you want a patient who's holding the book for the first time to get? What do you want them? What's the message, the the the elevator pitch to a patient?
SPEAKER_01Oh, I love that. Well, I um I will say that, of course, by the way, I am a firm believer in all of our evidence-based treatments for breast cancer, and that is what I do every day in my job. But in addition to that, there really is good evidence that thinking about the pillars of lifestyle medicine are a key component of treatment for our patients during treatment and during the survivorship phase. So I want to convey a message of hope and that there are things that you can do that you can control as you are going through your breast cancer treatment and beyond. And those are really choices you can make each day about how you want to perhaps incorporate more physical activity into your routine, or think about what you're eating each day, or think about getting more sleep and some strategies to work on that, managing stress, improving social connections in your life, et cetera. So I hope this book provides people with hope that there's things they can do and take control of as they're undergoing their treatment for cancer.
SPEAKER_00The um it's interesting when when you say survivorship, do you believe that survivorship starts from the time of diagnosis or the time of completing therapy?
SPEAKER_01Yeah, so when I give talks on this topic, I usually share the National Cancer Institute definition, which does state that an individual with cancer is a survivor at the time of diagnosis and throughout that entire course of treatment, follow-up, and beyond, and that it also incorporates so many other factors, thinking about psychosocial factors, their community, what kind of support they have, financial toxicity, et cetera. So that's how I define survivor. That's why I think an individual at the time of diagnosis would benefit from a great resource like this book. I should also note we hear it from our patients every day. They are they are bombarded with information, whether it's on social media, TikTok, from friends, relatives, their neighbor, people in the grocery store about what kind of diet they should follow, what kind of supplement they should take. And people just don't know what to do. They are bombarded with this information. So I feel like this is a great resource that is evidence-based. All the references are there in each chapter. And I hope this is sort of this book provides some calm in a sea of madness, you know, for our patients who are going through navigating treatment.
SPEAKER_00Yeah, for for for sure. I I I tend to agree with your NCI definition and so on. The one comment I have is that the needs of a patient are a bit different when you're actively undergoing chemotherapy versus after. And what I love about your book is that you create this uh roadmap, and that roadmap does not ignore that some of these things could be during time of therapy. But I want to go through what you what you have is the paving step. Paving step. And you have that listed, but I'll let you I'll let you help us understand what are these. It's a nice mnemonic, it makes people actually remember all of them, but each letter signifies something. Do you want to take us through those?
SPEAKER_01I'm happy to do so. And by the way, shout out to Dr. Beth Frades. This is, you know, this is her beautiful mnemonic that she created. She's very good at creating mnemonics. Um, but I will acknowledge that it does make it easy to remember what the 12 steps are in the program that we focus on with our patients. And so, and I will say that as Dr. Frades would state, the goal is to help people achieve a healthy body, peaceful mind, and joyful heart by following these steps. So again, P is for physical activity, A is for attitude, V is variety, I is investigations, and nutrition, G is goal setting, and then we get to steps. So social support, timeouts, energy, purpose, sleep, and then social connection. So I know that's a lot that I just shared, but we really take a deep dive into each of those topics in this program and in this book and describe how each topic is relevant to breast cancer survivorship.
SPEAKER_00I'm not being salesy, but I really genuinely believe that every person who is dealing with breast cancer should pick up this book. Um we'll go over a few of these things, but part of the reason is you actually have a lot of graphs and figures and charts and like I could like it's really a guide. It's a guide for me as a patient and so on. Before we go into a couple of these um paving steps, because I want to dig deep into a few of them, not all of them, we don't have the time. If I'm a caregiver, do you think this book is for me?
SPEAKER_01Absolutely. I do think this is a helpful resource for caregivers because you know, when you're caring for someone going through cancer treatment, you want to know how can I best support this individual? And, you know, this book does provide, you know, lots of information. In color, by the way, so it's kind of fun to read with you know strategies that can help a person going through cancer treatment feel better. And so I think as a caregiver reading this book, you know, learning about how to help someone sleep better, how how to help me there's their stress, maybe some interesting recipes, including mocktails. You know, so there's some fun things in here that I think a caregiver would benefit from so they could share it with their loved one who's going through treatment.
SPEAKER_00So let's dig deep a little bit into a few of those. Um, first one I want to talk a bit about is nutrition.
SPEAKER_01Yeah.
SPEAKER_00And the reason and the reason I want to bring this up is because um I'm actually airing this soon an episode about food and cancer with Dr. Irvi Shaw from Memorial Sloan Kettering, because she does a lot of that work. But with nutrition, Amy, there's so much out there.
SPEAKER_01Yeah.
SPEAKER_00I mean, I cannot tell you how many curbside questions and texts I get. Should I go on this and that? Is there a simple way that you would advise women with breast cancer the type of nutrition that they should follow or diet?
SPEAKER_01First of all, I love that you're interviewing Dr. Irvi Shaw. She's a friend of mine, she's amazing. And I learned so much from her as well. So I know she would agree with me. You know, we really counsel our patients with cancer to follow what we call a plant predominant diet. And what does that mean? I like to keep it very simple for my patients as well. And so there's this, I'm looking for the figure in the book, but we have a picture of a plate. So if you think of your plate at dinner time, half of that plate should be fruits and vegetables. And the more colors, the better. And then a quarter of that plate, some type of whole grain. And when I say whole grain, just because that gives more fiber for our diet. So quinoa, brown rice, whole wheat pasta, that's what I mean by a whole grain. And then a quarter of the plate, some type of protein. And maybe that's a plant-based protein, or maybe that is chicken or fish. Certainly we recommend limiting red meat and avoiding processed meats. But just thinking about the plate in that way, half of it, fruits and veggies, whole grains and a protein, makes it very simple, I think, for our patients to understand, especially when there's so much noise out there. And then, of course, we can get into the nitty-gritty about what are some of the actual recommendations, if specifically about our diet, that we should focus on. But I agree with Dr. Shaw, who would really highlight the benefits of fiber. You know, her research is very much focused on the importance of fiber in our diet to help us achieve a healthy, diverse gut microbiome. And that's certainly true for our patients with breast cancer as well. Fiber is so important. And many women in the United States are getting, we're we're fiber deficient. We actually are like less than 15 grams of fiber per day, and we're supposed to be getting like 30, you know? So fiber is really important as well.
SPEAKER_00How much do you think the deficiency uh in fiber is because of the type of food that we eat versus lack of knowledge and education?
SPEAKER_01Um, it's a great question. I probably a little bit of both. I mean, if you think about our diet, I mean, I eat a very healthy diet. But if I, you know, sometimes I have actually tried to calculate how much fiber do I get in an average day? And, you know, you have to actually put thought into it to make sure you're getting all those fruits and veggies in throughout the day, thinking about maybe a cereal that's high in fiber, thinking about the whole grains. But I do think with our current standard American diet, if you're not intentional about it, you're just not gonna get enough fiber. So I think it is a problem, especially also with all the processed foods out there, which obviously are not gonna have fiber in them.
SPEAKER_00You know, we all have our, you know, you know, thing that we really like that we know is not always healthy. And it's one of those things when you are diagnosed with cancer and getting through treatment, you st you want to have these little things sometimes in life that um that you'd like to experience. I tell you, for me, um I like French fries, and I think I have a sweet tooth, especially after dinner. I know both are not healthy. But if you have a patient, you're not telling them you can never ever eat a French fry or have a little bit of a dessert or ice cream, right?
SPEAKER_01Definitely not. Okay, we're not, we're not here. We're giving, like, if you're thinking about your diet over the course of many months over a year, this is how you want to think about it. But of course, we all have our indulgence once in a while, and that is part of life. And a big part of this book is focusing on how one can experience joy throughout this process. So if you love your French fries, yes, eat them. If you love your, you know, a little bit of ice cream after dinner, of course, we're not gonna say no to that, but just generally thinking about principles for how to improve one's diet.
SPEAKER_00Two questions uh really important as we talk about nutrition alcohol intake, and then is there any evidence that keto diet uh really helps reduce breast cancer or improve the uh livelihood of women with breast cancer?
SPEAKER_01Right. So, in terms of alcohol, I know nobody likes this one, but you know, organizations such as the American Institute of Cancer Research, American Cancer Society really do, you know, come out with pretty clear guidelines that really alcohol is unfortunately not safe when we're thinking about not just breast cancer, but other types of cancer too. We know it is a carcinogen, and so we do have to be mindful of that. And actually, over half of Americans are not even aware that alcohol can increase risk for cancer. So that's like something we all just have to say, even though it's not fun. So I do counsel my patients, I don't tell them you have to completely eliminate alcohol from your diet 100%. But I do recommend that people are mindful about why they're drinking. So obviously, if you're at a wedding or it's New Year's Eve or Valentine's Day and you want to have a glass of wine, you know, have your glass of wine, but think about don't just, you know, sometimes in our culture there's a lot of mindless drinking. You know, you go out and have too many drinks with your friends, just being mindful about how many drinks you're having, why you're having it. And I think that's really important. And, you know, we are at a time where mocktails are having a moment. Just kind of tell us about that.
SPEAKER_00Tell us about the mocktails.
SPEAKER_01Well, actually, there's like, I have to, I'm scrolling through my book, but um, there's this wonderful nutritionist who um her name, she has a great um Instagram page called um Cancer Nutrition HQ. And so she often does these videos where she's making an exciting mocktail. Okay, so she we we shared one in the book. It was a um, I want to say it's a watermelon mojito recipe, okay, that she shared with me that's in this book. And it looks so beautiful. So when I saw her share that, I was like, can I please put that in the book? And then another drink that's actually there is research to show that tart cherry droop, tart cherry juice is actually beneficial for women with breast cancer on aromatase inhibitors. There's actually research to support it can help decrease the joint pains that people experience. And so a nutritionist I work with, Carol Sullivan, will put the tart cherry juice in a wine glass. And it looks like a beautiful glass of wine. Yes, I agree, it tastes differently, but it kind of gives that vibe of like, I'm drinking this delicious drink out of my wine glass. And so that's another potential substitute for people who really just like holding the wine glass and sipping something yummy. So there are lots of strategies out there to help people cut back on alcohol, but I do think that's an important one. Getting back to the keto diet, that's another great question. And you mentioned Dr. Irvi Shaw earlier, and she and another wonderful colleague, Dr. Neil Ayengar. I know they had this paper they published a few years ago looking at, you know, the merits of a plant-predominant diet versus a keto diet when it comes to cancer. And at least in my breast cancer population, I very much recommend more of the plant-forward diet, again, because of the benefits of the fiber intake that we know are so important for our gut microbiome and potentially responsiveness to certain treatments, such as immunotherapy. So I would lean towards that diet recommendation based on the current evidence, but there is some interesting research being done on ketogenic diets and certain subtypes of breast cancer. So I'm looking forward to learning more about that.
SPEAKER_00Okay, let's talk a bit about sleep, because I don't sleep well, so I'm pretty selfish here. I want to try to understand the sleep piece. How, I mean, tell us how do we get patients to sleep better? Because again, it's one of those things. I I don't need to see a trial, honestly, that sleep is good for you. Like, you know, uh so, but how do we get them there? How do we get all of us there?
SPEAKER_01Right. So, you know, sleep disturbance and insomnia is very prevalent uh among our patients. Let's just focus on the patients. For now. I know I don't sleep great either. Um, but unfortunately, my patient population, oh my goodness, there's so many reasons they're not sleeping. Maybe it's hot flashes, maybe it's pain from the recent surgery, maybe it's a lot of times it's anxiety, fear of recurrence, all those racing thoughts that come at night. And so I'm very fortunate where I work to collaborate with a wonderful colleague. Um, shout out to Dr. Daniel Hall. He's a psychologist who is doing some interesting research using cognitive behavioral therapy for insomnia, specifically adapting it for cancer survivors. And actually, he has a few clinical trials open now that are done via telemedicine. So it's easy for patients to enroll. And so they're getting access to training for CBTI based on their needs as a cancer survivor. And many of my patients who have been on that intervention arm have told me how much it's helped them. I don't know if you know much about CBTI. Um, I know a little bit about it. I've never actually tried it on myself, but it does seem really challenging, but it is effective for addressing insomnia.
SPEAKER_00So yeah, yeah, interesting. Do you um, I mean, patients can obviously, depending on the cause, obviously you have to decide whether they take medications or not.
SPEAKER_01Yeah. And obviously, thinking about sleep apnea and other causes that may need to be evaluated. But you're right, thinking about, you know, you know, I usually try to avoid prescribing medications to help people sleep unless, you know, they're in the midst of chemo and they really do need a little help with something. But in general, trying to work on these strategies. I mean, CBTI, the bottom line is using the bed for sleep or sex, and that is it. So if you're up in the middle of the night and you pick up your phone and you scroll on social media, that's a big no-no. You have to like get out of bed and train your body to only use the bed for sleep. So it is definitely challenging. But patients who have done it, you know, my patients who have participated have noted that it really did help them improve their sleep. But I will acknowledge I'm a work in progress myself.
SPEAKER_00When, Amy, when you talk about attitude, I I think, you know, obviously having a positive attitude towards anything in life is better than having a negative attitude. But are we really able to link attitude to recurrence, to anything more than just simply it's a good thing to have? In other words, are we able to tell a patient that by exercising the physical activity and having a positive attitude, you will have lower risk of breast cancer recurrence, or we just tell them it's something good for you to have because it's gonna make you feel better. What are these endpoints when you talk about following these type of recommendations?
SPEAKER_01Yeah, well, one interesting study to share just in general about the benefits of lifestyle interventions for breast cancer survivors, is this study called Dell Cap. It was published just a few years ago in Gemin Network. The lead author is Dr. Kanyoto, but basically it was um looking at it's an observational perspective cohort study of about 1,300 women with higher risk breast cancers who were enrolled in this trial. And this part of the study, prior to starting treatment, you know, during treatment, a year after treatment, and two years after treatment, these individuals filled out questionnaires about their lifestyle habits. And they're really very similar to the ones we discussed earlier, really looking at their physical activity habits, their diet, how many fruits and vegetables were they eating, how much processed meat were they eating? Were they drinking sugar, sweetened beverages, how much alcohol were they smoking? So they're asking them all these questions and created this lifestyle index score. And to make a long story short, when they followed these individuals over time, those individuals who had a higher adherence to these lifestyle recommendations had a 37% lower risk of disease recurrence and a 58% lower risk of mortality. Okay, so those who could adhere to these lifestyle factors, again, it was an observational study, but did have better outcomes. So this is, we show this in the beginning of the book, this and other studies. You know, these lifestyle recommendations really can improve outcomes. So I do think these are a very important component of standard treatment. Um, getting to your question about attitude, certainly when we talk about attitude, that's of course, we're not trying to be all polieta, you know, about it having cancer, not by any means, but thinking about strategies to help people with coping, coping with fear of recurrence, coping with the stress of cancer, coping with the uncertainty, all the things that one has to navigate. And we just know that adopting those strategies obviously makes the treatment journey so much easier to navigate. It's never easy, by the way, but a little easier to navigate.
SPEAKER_00You you I mean, what what at what level you feel that a patient needs a referral to a psychologist or a psychiatrist? I've heard two schools of thoughts, and you tell me your opinion. Some school of thoughts it's always having a psychologist involved from the get-go is always helpful, and they may not need to be involved a lot, but I always send my patients to a psychologist. And the other school of thought, I make the determination which patient needs a psychologist or not.
SPEAKER_01Right. So I wish we had psychologists for every patient because I do think it's our psychologists provide so much benefit to our patients as they're navigating their diagnosis, treatment, and beyond. Certainly, you know, our psychologists also have limited bandwidth. So presently, I refer people who really I think would benefit from that consultation, but I do think everyone would benefit. I should tell you, my background back in the day, I thought it would be a neuroscientist and psychologist. So I'm really partial to that and um feel like my psychology colleagues have so much to add, and I've learned so much from them along the way and continue to learn from them every single day. So I'm a big fan, but I also recognize that their bandwidth is limited too. And you know, that is an issue in oncology care, just having more access to mental health support is so important.
SPEAKER_00Yeah, yeah. Okay, let's talk about uh timeouts. What are we doing here?
SPEAKER_01I know, I know this is another one we could both learn from. I mean, I'll just speak for you, but I'll speak for myself. Like really the importance of, you know, you know, thinking about the concept of self-care, taking time for yourself. And I will say this is an important topic. So, you know, our patients who have participated in this program are women, those who have participated. And in general, and I know I'm making a large generalization here, but many of them share that they're taking care of their kids, they're taking care of their partner, they're taking care of the meals, they're doing the laundry, like again, generalizations, but many times that is the case. And we really talk about the importance of when you're going through cancer treatment and in survivorship, taking some time for yourself to do maybe take a walk outside, get into nature, you know, finding time to learn how to manage that stress, connect with others who are going through treatment and how there are so many benefits for that in terms of our health. So that's really what the timeouts um chapter is about. Thinking about taking some time for you.
SPEAKER_00You know, and the social connectedness is uh this is when you try to connect with other people. Are you talking about support groups? Are you talking beyond that?
SPEAKER_01Well, I love this topic. And I certainly have always, when I first started running this program, I really underestimated the importance of social connection. And actually, if you look at that really interesting study, it's called the Harvard Study of Adult Development, where they've followed young men for like now, it's like some of them have been followed, I think, for like 80 or 90 years, and they've surveyed them over time to see what factors in their lives have resulted in the most immense benefits in terms of their well-being. And number one is social connection. So connection with family, friends, coworkers, whoever that may be, over the course of your lifetime does bring the greatest sense of well-being, which is pretty amazing. And we've witnessed that in our program as well. Many of the patients will tell you, like, I loved everything I learned. I love learning about exercise. I'm eating 30 plants a week for my healthy gut microbiome, but having other women in my circle now who understand what I'm going through, that's like the greatest benefit. So I feel like paving is more than a support group because it's also like empowering people with things they can do to improve their lives in this supportive community.
SPEAKER_00Amy, without sharing any private information, do you have enough case studies where you could share with listeners and viewers a story or a couple of patients kind of before and after the paving step programs where they followed this? And what have you noticed? Is there enough N, I guess, to be able to share some stories?
SPEAKER_01Oh, definitely. And in fact, in this book, we do share many stories. So we have something called a live and learn in each of the chapters. And these are paving graduates, so women with a history of breast cancer who went through the program who were so inspired by perhaps a particular topic or lesson that they learned that they wanted to write about it and share. And I got permission for them to publish it in the book. And so there are so many great stories. And um, I actually just want to read, I just literally flipped open the book to a lovely um reflection from a patient named Jane France, who was in the very first paving group back in 2019 when I first launched this program. And she, those those ladies still are connected. They continue to meet on Zoom twice a month. They call themselves the originals. And so Jane shared this cancer will always be a part of my life, and I want to keep it in perspective. But paving and my paving pals have helped me do just that. And she goes on to just explain how you know nobody really gets you when you go through cancer treatment. But the power of this program is to be exposed to other people who get it and who are also interested in learning about lifestyle medicine to improve their health. And so she's so inspiring. And so many of the reflections in this book are quite inspiring. And I hope, you know, other patients who read this will feel that way as well.
SPEAKER_00Have you gotten any reaction from your uh colleagues about the book? Have you had some folks who may be a bit dismissive about some of this, or was it all positive?
SPEAKER_01Great question. You know, I've definitely shared it with my colleagues, certainly, you know, my MGH breast oncology colleagues, and definitely some colleagues at many other institutions. You'll see at the beginning, I probably got a little I have a lot of endorsements for the.
SPEAKER_00I think that's the most endorsements I've seen in any book.
SPEAKER_01I think I had a little too much fun with that because I was telling a lot of my colleagues about the book, and then I got them a copy. And so they were so kind and generous. So I kind of, you know, I'll just, you know, I'm so grateful to so many of these folks for their lovely endorsements. Um, you know, many of my colleagues are really passionate about survivorship, like Dr. Miriam Lusberg, Dr. Eleanor Taplinski, Dr. Elizabeth Koman, Dr. Corinne Men. These are colleagues of mine who share this mission to help empower patients with breast cancer to live their lives fully and adopt healthy habits after diagnosis of cancer. So they've been super supportive. Okay, are my are all of my colleagues super supportive? I mean, nobody said anything negative, but you're absolutely right. I'm not really, I'm not really looking for feedback from everyone. I feel like I'm helping people. And most importantly, I care about what my patients think and what kind of resource they find this book to be. And I can tell you that the feedback I've gotten from not just my patients, but honestly, women all over the world. And that's been really wonderful. People in Australia and New Zealand saying, How do I get this book shipped to me? I really want this book. I mean, to me, that was the purpose of writing this book. So I'm not really looking for approval from the whole world of oncology. I just want to help the patients who are going to benefit the most.
SPEAKER_00There's no question in my mind, patients are going to be benefit, the benefiting in this. But um let me ask you, speaking of which, um the this the the when you started writing the book uh several years back, is this going to be living and breathing documents where you feel there's a next edition and so on because things do change? Like what's your yeah?
SPEAKER_01I do think so. I mean, that's the thing about writing a book, right? You're in oncology, especially, like our field thankfully rapidly evolves so quickly. So even though this just came out, I'm already like taking notes. Okay, I'm not gonna update this chapter with this information, you know, for the next edition. So I do think, you know, it will, I will definitely plan to update it as more research evolves, especially, you know, the interesting research coming out. Let's just talk about nutrition and thinking about the gut microbiome. There's a little bit about that in this book, but I'd love to have more. And so similarly with exercise, as we await further data from the Be Well study in terms of weight loss and breast cancer outcome, like all of that information I will want to update as that information matures.
SPEAKER_00Where do you discuss finances and financial toxicity?
SPEAKER_01That's a really great point. So, financial toxicity is certainly a key component of survivorship care, included in that National Cancer Institute definition. I know I described that in the first chapter or one of the first chapters when we describe what do we actually mean by survivorship. But do I, and I probably share some resources in here about how to get help along your journey in terms of whether there's a social worker that you can work with in your cancer center or a case manager to get support in terms of managing financial toxicity. But you're absolutely right. That is definitely on the top of minds of many of our patients, and we do need to think about how other strategies to help them with that.
SPEAKER_00Yeah, you know, I I sometimes patients don't know what to do with their finances when they're diagnosed. There's one element financial toxicity, which is how do I handle the cost of care when I'm actively getting therapy? But what I was struck when some patients would ask me, Well, what do I do with my 401k? I have a 401k. Do I keep contributing to it? Do I withdraw money from it? Like there are certain things that I personally, as an oncologist, did not think about. And I I think uh I think I think they're worthy of at least trying to understand how do we handle the answers to that.
SPEAKER_01Great. I mean, I welcome your advice about that. That definitely is not in the book. We need some more information about how the counsel patients or resources for them to help someone else counsel them about those issues for sure.
SPEAKER_00Um what what um you know, as what how in general, the reception obviously you've told me has been positive and everything. Were there anything that you learned along the way as you were writing about yourself, about certain things that you would want to do? You are an extremely busy, successful oncologist, you're wearing so many hats, and I could imagine you could get overwhelmed sometimes with all of this. So did you find certain things about yourself that you wanted to apply? Say, like, you know what, I'm not taking enough time out. So I'm not really um no. I mean, I do think actually, I do think us as oncologists, we don't really always uh, you know, do a good job in our self-care.
SPEAKER_01Yeah, I am a great example of that. Unfortunately, because while I was finishing the last last edits on this, I was trying to train for the New York marathon, which was like, and I did run it for a charity, and I will acknowledge like it didn't go so great for me because I was definitely under trained and sleep deprived. And so, yes, we all take on too many things, and that was actually a good lesson for me. So I'm trying to do a better job myself, New Year's resolution to prioritize sleep more, because we, as we talk, sleep is a common theme in this conversation, like that's something I know we all need it, right? It's obvious. And to try to tackle on these big goals, like getting the sleep is going to be important. But um, that is one I definitely need to work on. One topic, though, that is in a positive light that I love, um, chapter 13 in this book, which is focused on purpose. We actually called it purpose and possibility, charting a fulfilled life. I really love this discussion about how one's sense of purpose and meaning in life may change after a diagnosis of cancer. And, you know, this is always a really great discussion in our paving groups. And I see we shared some reflections from some patients who participated in paving who share how their cancer diagnosis treatment um really did change how they thought about their own lives and how they're living them. And so, you know, this book is part of my own sense of purpose, like bringing these tools to breast cancer survivors, not just at my cancer center in Boston, but around the world. And so I hope I can continue to do that.
SPEAKER_00So a few questions before I let you go, is I'll call those like rapid fire. Give me one habit you wish every survivor would try for one week.
SPEAKER_01Ooh, one habit. So gee, that every person would do for one week. Well, here we go. We know we talked earlier that we were all not getting enough fiber in our diet. So I would say each day, make sure you're adding one extra serving of a fruit or vegetable to your diet. It's not that hard. So one extra serving. Maybe you have an apple for a snack instead of a granola bar, or maybe you have a green vegetable at dinner that you haven't had before. Trying something new is always fun. And we talk a lot about that in this book, trying a new veggie or something like that. So that there's my answer.
SPEAKER_00Is there a belief about survivorship that you've completely changed your mindset about?
SPEAKER_01A belief that I've changed my mindset about.
SPEAKER_00Well, you know, in certain things, sometimes we have certain preconceived notions, right? But then then you've researched this. Then you've actually now.
SPEAKER_01That's actually a great one. I've learned another area that I'm trying to learn much more about and hopefully do more work in is the area thinking about addressing menopausal symptoms in cancer survivors and sexual health and all the symptoms that our patients with breast cancer and many other cancers experience. And so learning a lot from my women's health colleagues that vaginal estrogen is safe in individuals with a history of breast cancer, even ER positive, learning more about that, learning about other tools to help our patients manage, unfortunately, all the whether it's hot flashes, vaginal dryness, low libido, joint pain, whatever it is. I want to learn more about that to help our patients. And so that's an area that my patients have been telling me about for years too. But I'm trying to help them more with that.
SPEAKER_00That's your next book. And I, you know, it's it's becoming a bit confusing with hormone replacement therapy. Like, you know, what to what to do with that? What are you telling your patients now about hormone response therapy?
SPEAKER_01Well, I did actually just I attended my first menopause meeting last fall, and I got certified as a menopause practitioner. So I am trying to learn so much. Um, I have been prescribing vaginal estrogen, and I'm open in some cases to prescribing menopause formidal therapy, but I will say that I'm learning more from my colleagues about this. And definitely there's lots of risks and benefits and lots of research that we still need to do to sort this out, but a growing area. Next episode.
SPEAKER_00Yes. Last question is there a question you wish that your patients would ask you more often?
SPEAKER_01Ooh, that is such an interesting question. Well, as we talked a few minutes ago, I love this um focus and the book on purpose, sense of purpose after a cancer diagnosis. And I guess I would like to maybe ask my patients a little bit more about how their experience as a cancer patient changed their life? Has it changed their sense of purpose? Are they looking for other ways to find meaning in their life? And so maybe that could be a joint conversation, but I'd love to learn more from my patients about that.
SPEAKER_00Amy, anything I should have asked you about the book, about what you're writing, about anything that I completely overlooked and forgot.
SPEAKER_01I think you're an amazing interviewer. I really appreciate this opportunity to discuss the book. And there's not any specific thing, but I'm so grateful for this opportunity.
SPEAKER_00Congratulations on the book. The book is called Paving Your Path Through Breast Cancer and Beyond. And where do people can find it? Is it available everywhere or specific orders?
SPEAKER_01So it's it's on Amazon right now. It does get sold out from time to time, but it's there right now. And our publisher is healthylearning.com, and they will ship anywhere in the world. So um people can order it directly from the publisher as well.
SPEAKER_00Congratulations, and I can't wait to read your future books.
SPEAKER_01Thank you.
SPEAKER_00Thank you so much, Dr. Commander, for coming on the show. I appreciate you joining us and talking about your book. I also want to congratulate you and your co-authors on an amazing book that I think everybody should read and pick up a copy and really understand all of the valuable lessons that stem from this book. Um, folks, you can subscribe to my show and rate it and let others know about the podcast. You can review the podcast, you can join the conversation, and check out both of my books, Toxic Exposure, The True Story Behind the Monsanto Trials and the Search for Justice, and The Cancer Journey, Understanding, Diagnosis, Treatment, Recovery, and Prevention. My third book is coming out, AI and Cancer Care When Machines Meet Modern Medicine. Before I let you go, I'm gonna leave you with a saying by Pablo Picasso. The meaning of life is to find your gift. The purpose of life is to give it away. Until next time. Take care.