Is it fair that I say – yet again – that this was one of my best conversations of the year? A deeply personal, honest, scientific, evidence-informed (and pearl-ladened) conversation on cancer and recovery, and completely from the heart. Dr. Patrick Hanaway, MD is a mentor, a colleague, a friend, and an amazing guy. His journey as a leader in functional medicine through stage IV laryngeal cancer and his embrace of a metabolic approach is profound, and something you’re going to want to hear.
His transformation took him to the Sierra Madres in Mexico to learn indigenous healing approaches from the Mara’akame, and back to his functional and integrative medicine roots exploring the research on using ketogenic and fasting dietary approaches alongside chemotherapy and radiation therapy. He does a fantastic job explaining the mechanisms of a ketogenic diet for cancer and how to support immune resilience through nutritional and herbal interventions.
Dr. Hanaway is an inspiration always, and especially during the holiday season, and a bright light to me personally. I hope after listening to his profound journey in this podcast, that he is the same to you! Please share, leave us a review and a rating, wherever you listen to New Frontiers. Thank you and enjoy! ~DrKF
Stage IV Cancer: Dr. Patrick Hanaway’s Personal Experience with Functional & Integrative Modalities
As the second leading cause of death in the United States, a cancer diagnosis is often met with emotions such as grief, fear, concern, sadness, anxiety and the reality of mortality. Our guest today, who has been a fundamental leader in the evolution of functional medicine, embraced his stage IV cancer diagnosis as an invitation to transform his life. Dr. Patrick Hanaway is a board-certified family physician and Chief Medical Education Officer at the Institute for Functional Medicine (IFM) and recipient of the Linus Pauling Award for his outstanding work in medical education and research. In this episode of New Frontiers, Dr. Hanaway talks with Dr. Fitzgerald about his healing journey using a functional and integrative approach alongside shamanic practices, chemotherapy, and radiation therapy.
In this episode of New Frontiers, learn about:
- Using ketogenic and fasting diets alongside chemotherapy & radiation therapy
- The most common cancers associated with insulin resistance
- How fasting affects chemotherapy and radiation therapy effectiveness
- Mechanisms of the ketogenic diet for cancer
- Optimal ketosis and beta-hydroxybutyrate range for cancer
- Insulin and Insulin-like growth factor-1’s (IGF-1) role in tumor proliferation and growth
- The role of the microbiome in immunotherapy, including akkermansia, bacteroides and bacteroidetes
- Using diet to create a differential stress resistance
- Nutritional and herbal approaches to boost immune resilience
- High dose resveratrol as an adjuvant in cancer therapy
- Personalized approach versus one-size-fits all
- The importance of self-care in long-term maintenance and remission
Dr. Kara Fitzgerald: Hi, everybody, welcome to New Frontiers in Functional Medicine, where we are interviewing the best minds in functional medicine, and today is no exception. I am very honored, and just thrilled to be sitting here with my dear friend and mentor for years, Dr. Patrick Hanaway. I want to read his full background to you before we jump into our conversation.
Because it not only is it important to our talk today, but what Patrick has been doing, and he continues to do for functional medicine, I think is important and impressive. And I just want to highlight some of that. So, he’s board-certified in family medicine. He trained at Washington University.
He has served on the executive committee for the American Board of Integrative Medicine. He is past president of the American Board of Integrative Holistic Medicine. For more than 20 years, he’s been working with his wife, Dr. Lisa Lichtig in clinical practice in Asheville, North Carolina, and they just continue to do that to this day.
He was the CMO at Genova Diagnostics for a decade, and then he became the Chief Medical Education Officer at IFM. Many of you probably met him during that time. He oversaw the development and implementation of many of the programs that we teach. And he has also taught with IFM since 2005.
So, he’s been just a fundamental player to the evolution, and just radical expansion of functional medicine across the globe. In 2014, he worked with Dr. Mark Hyman to develop the collaboration between IFM and Cleveland Clinic, where he was the founding medical director, then research director at the Cleveland Clinic Center for Functional Medicine.
He’s currently a research collaborator there. Oftentimes, you’ll hear Patrick present at either IFM AIC or PLMI, the Personalized Lifestyle Medicine Institute on the research that they’re doing over at the Cleveland Clinic Center for Functional Medicine. And it’s a whole other podcast. It’s a whole other conversation.
But we can link to the JAMA Network publication, the first publication I think that they put out, and I know there are more publications to come just really showing what functional medicine is capable of doing. In 2018, Dr. Hanaway was diagnosed with Stage IV laryngeal cancer, and his life has been transformed through functional and integrative approach.
Including nutrition, shamanic healing, acupuncture, herbs, prayer, chemotherapy, radiation therapy, community support, spending time in nature and love. Recent medical assessments demonstrate no evidence of disease, and life continues to be filled with uncertainty. The primary focus of Dr. Hanaway’s work is to leverage his skills and knowledge to transform medical practice through education, research, and clinical care.
Importantly, Patrick was initiated in 2009 as a Mara’akame. You can let me know if I said that right, Patrick. Indigenous healer by the Huichol people, and correct me there, of the Sierra Madres in Mexico. He holds community fires, lead ceremonies, and offers traditional healing sessions. Dr. Hanaway, welcome to New Frontiers.
Dr. Patrick Hanaway: Kara, thank you so much. Mara’akame. Mara’akame is the name in the Wixarika people, the Huichol people of the Sierra Madres. One who knows, I don’t really know, but it’s trying to walk with feet in both worlds. I’ve heard this introduction. And it’s funny to me because I’m sitting here actually crying.
Because all the aspects of what I’ve done in functional medicine, and integrative medicine, and work in clinical, and then it’s this memory of being diagnosed with cancer, and the work that is really changing my life. And it’s more full, and it’s more alive, and it’s what we’re going to talk about today, I think. At least some of it.
Dr. Kara Fitzgerald: Yes.
Dr. Patrick Hanaway: And wow, we’ve known each other, I don’t know, 13, 15 years. I’m honored to think that you consider me to be a mentor of sorts, because I consider you just to be a colleague, and someone who’s bringing both enthusiasm, and intelligence, and discernment, and wisdom to how do we apply this in a bigger way. So, I’m a big Kara Fitzgerald fan, and I’m just glad to be here with you in this conversation.
Dr. Kara Fitzgerald: Oh, thank you. It’s just really lovely. Oh, my goodness, Dr. Hanaway. Yeah, very lovely. It is. it’s great to be with you, and it is. It’s an honor to get to move this paradigm forward. To be a part of birthing this paradigm into the world. You’ve always been one of the most authentic humans out there regardless of what hat you were wearing, what impressive lecture you were delivering, what research you were involved in.
You’ve been extremely authentic. And I would imagine that comes from your spiritual practice, but at least in part. But you were diagnosed with cancer. I remember PLMI right before your diagnosis, getting to hang out with you a little bit, and just here I am reflecting on when you were diagnosed, just thinking about that last time that we had hung out a little bit. I don’t know, I don’t think that you actually knew then.
Dr. Patrick Hanaway: Oh, no. No.
Dr. Kara Fitzgerald: And just wondering, how are you feeling? You seemed busy. But we’re all burning the candle excessively. You did have a lot going on. You’re talking about your research. But what I want to point out, I want to hear about that, that transition into the diagnosis, and what you did. I think we all want to know because cancer is ubiquitous, and it’s also the great unknown, and it’s scary.
So, I want to know that piece. But I also want to say that, if it’s possible, your authenticity has your presence, you’ve shed something so profoundly in your journey of recovering from… of submerging into, and then recovering from cancer. And who you are today is more authentic and transformed. And I want to talk about all of that and spend some time in the science. So, hopefully, we can do that in 50 minutes. Okay, go, go.
Dr. Patrick Hanaway: That’ll be a journey. But I’ve said to patients for 30 years, cancer is about transformation. It’s the invitation. It’s like something needs to change in your life. And if we look at it, cancer is growth out of control. And so, what in your life is growth out of control at this point in time? And growth out of control that is not allowing you to bring your own vision, purpose, and meaning to life.
How are you not doing that? And in my case, in particular, it’s sitting in the throat, on the left area, epiglottic fold. It’s a laryngeal cancer. So, to be esoteric, it’s that fifth chakra, like what is not being expressed in a way? And having integrity and authenticity is important in how was I not speaking? What was the truth in my heart? And that was part of the question. And you talk about, it’s a fascinating… I remember that PLMI meeting in Seattle. No, that one was actually in Arizona.
Dr. Kara Fitzgerald: Chicago? Oh Arizona, okay?
Dr. Patrick Hanaway: And it’s funny because I spoke about I had been diagnosed eight months before with a central retinal vein occlusion, and that was related to weight gain, and insulin resistance. I’ve lectured on this, I know about this, but I was living a life of travel, and movement, and not caring for myself in a way. And I began to do that, and I spoke about that.
And on the way back, it so happened that I ended up being seated next to my friend, and colleague, and mentor, David Perlmutter on the plane. We were on a four-hour plane flight together, sitting next to each other. And we just got to visit, and he talked about how, “Patrick, you’re authentic, you’re not being the guru, the knowledgeable one. You’re actually speaking from personal experience, and allowing people into your lives, and that is what is necessary.”
And he said that to me at that point in time. And that was what would end up being some four, maybe four-and-a-half weeks before my diagnosis of cancer. And then, moving forward, being at home, and having an event. We have events in our home in the Smoky Mountains, and on our land. And we had two indigenous elders from Canada, from Manitoba, Dakota elder, who we’ve sponsored before.
And they were here, and we were with them, and they were living with us, and we had people. And when I felt this lymph node on my left neck, and it was hard, and firm, and it wasn’t tender. And I’m like, excuse my language, but I was like, “Oh, fuck.” And I was so scared that I didn’t tell anybody. I didn’t tell my wife. And I called, and I made an appointment to be seen.
They were leaving on Sunday, and everyone was leaving on Sunday, and the soonest I could get in was Monday. And I made an appointment on Monday to be seen by the ENT doctor. And it was like, and I knew, and I was afraid to even talk about it. To even let these people know, and my wife know. And it wasn’t until everyone left in that night before, I said, “I got to go to the doctor tomorrow.”
And that was Monday, and he did an aspiration, and we got the path back on Tuesday night that said squamous cell cancer. Obviously, it’s a met. It was in the lymph node. We didn’t know where it was from. I got a PET scan on Wednesday, next morning, and fortunate because we’re doctors, and being able to maneuver through the system very quickly, and do that. And it’s like, “Oh, it’s on the left area of the epiglottic fold.”
And there are four lymph nodes on the left that are all positive, and several on the right that may be positive, clearly Stage IV laryngeal cancer. And this is the day before Thanksgiving. And then, the next day, sharing it with our two sons who are in their mid-20s about this on Thanksgiving Day. And that was the beginning of the journey. And part of that was me embracing.
It’s like, “This is transformation, I’m going to do what I need to do to make changes.” And we’ll talk about that journey, which included a lot of different things. And one of the biggest pieces that I want to talk about is nutritionally, what happened? I was aware of those things, but I just deepened into an understanding of how to work with it. And it was not the only thing, it was one of many, many aspects of the healing process.
Dr. Kara Fitzgerald: Yeah. I want to go there, and I want to talk about it. I understand the impulse to want to hide, and I’m sure a lot of the clinicians listening to this would absolutely understand that, and just being so terrified. And then, it sounds like you surrendered. And there was a transformation that happened. It sounds like it was relatively quick.
Dr. Patrick Hanaway: It was. Well, and it’s still going on. So, it was both one of recognizing I need to ask for help. And you’ve seen me, Kara. I’m like, “I’m strong, I can handle this, give it to me, pile it on, I got it.” And it’s like, “No, no, no. No, it’s actually not that. It’s everything but that.” It’s be vulnerable, receive, ask for help, and that was hard to do, and absolutely necessary.
So, that was all part of the inner journey, and being able to move through each step of that. So, during the time, I was doing a preparation, a one-month preparation to be able to go on a pilgrimage in Mexico to a sacred site that I’ve been to many times before. And I asked the oncologist, who’s someone I’ve known for 20 years, and I asked the ENT doctor.
I’m like, “If I’m gone for 10 days, two weeks, is that going to make a difference?” And they’re like, “No, not at all. Go ahead, do what you want to do. We’ll be getting things prepared.” And so, I went on this journey. And Lisa, my wife, was with me. She also is an initiated traditional healer, a Mara’akame. I blame her, I said, “You got me into this in the first place.”
So, we went, and when we went there, and we were with some other people, other healers. And I asked the teacher and he said, “You’ve been praying for transformation, and change in your life. And here it is. It’s not the way you thought it was going to look, but here it is.” And it spoke deeply to me like, “Yes, that’s true. And what do I need to do to transform, to use this as a place of transformation?”
And we’ll talk about those things, and that was helpful. That journey was helpful, the deepening, the asking for help of my colleagues there. And also, then, the next part of the journey. I was like, “Really? Radiation therapy? Really? Chemotherapy? Do I believe in those things? Are those good things?” And yet, when someone holds their… do you remember that meme from maybe the late ’90s, or early 2000s, speak to the hand?
It’s like the hand is right in front of you. It’s like, “Oh, Stage IV cancer.” I’ve joked. I’ve said if they told me it was Stage II cancer, I’ve probably been like, “Nah, no problem. I got this.” But they say Stage IV cancer, “Oh, geez, I better really pay attention here.” And everyone I spoke to, and I had the great opportunity to speak to leaders around the world about this. And they all said the same thing.
This is what you need to do. And I didn’t really want to do it, but I said, “Look, I’m going to do everything I can.” And then, to have colleagues say, “Oh, that’s the wrong thing. You shouldn’t do that.” It’s really hard. And nutritionally, moving forward, I’d done work with L-Nutra, and ProLon, and metabolic changes, and I’ve done work, and I know those people. I know that research really well.
And I’ve done work with doing keto, and I dropped 30 pounds, and was in great shape. And insulin resistance was gone, and I’m in good shape coming into this. And it’s like, “Okay, well, maybe, okay, keto, keto and cancer,” the metabolic basis of cancer, and Tom Seyfried, and Dom D’Agostino, and Nasha Winters. And it’s like, “Okay, I’m going to reach out to those people. I’m going to connect, and I’m going to do that.”
And I did, and I jumped into it in a deep way. And we will talk about that, but I also want to just acknowledge that A, it’s not for everybody, but B, every cancer does not have an insulin resistance base glucose driven process. Some cancers do, some don’t. I’m fortunate that the cancer that I had, and the treatment using radiation therapy is specifically susceptible to, and benefits from a ketogenic approach.
But I had no idea of that at the time, when I called Tom and talked to him, when I called Dom and talked to him, when I made decisions of what I was doing. I got lucky. But as they say, luck favors those who are prepared.
Dr. Kara Fitzgerald: Yeah. Listen, I want to jump in to what you did in the nutrition end. I remember you put out an APB to everybody to just ask ideas. You’ve surveyed the land and you are, of course, you’re in a good position to be able to do that. But there are research resources now for regular people. I’m thinking of Tripping over the Truth or Tom Seyfried. I’ve got a podcast with him. I’ve got a podcast with-
Dr. Patrick Hanaway: I’ve listened to it.
Dr. Kara Fitzgerald: Yeah. And so, for folks just checking in here, there are resources for you even if you’re not a physician. To help tease out your cancer type, or if you’re thinking of a friend, or a loved one, or whatever where you can pull together an approach. And so, you did that, and you ended up designing your care team, and you had to just make a call.
So, even as you had colleagues disagreeing with your choices, you had to just let those go, and walk forward with what you and your family were determining. I’m sure your wife was… that you were in a really intimate communication. And you just-
Dr. Patrick Hanaway: And it’s an uncertainty, right? You don’t know the absolute truth of what’s going on. And so, it’s a part of gathering information, and then sifting through it, and synthesizing it, and then making a decision, and going forward, knowing that there’s uncertainty in the process.
So, to just state the most common cancers that are going to be associated with insulin resistance are going to be breast cancer, colorectal cancer, endometrial cancer, pancreatic cancer, glioblastoma multiforme. And then, the cancers that are treated with radiation therapy, primarily with adjuvant chemotherapy, which are going to be head and neck cancers, and anorectal cancers.
Those are going to be the grouping that are their best to be able to take a really strong insulin sensitization, ketogenic, do what you can with those. I’ll have to say, for the rest, we don’t know as much data. But for those, yeah, that’s a really clear thing that I think, yeah, going forward and doing that. And making that decision and talking to Dom, talking to Tom.
Making a decision of like, “Okay, I need to be tube fed because they’re going to be irradiating my throat, such that I may not be able to swallow food in the same way.” And the thing they don’t tell you is that, “Oh, and when that happens, you’re going to lose all your taste.” For me, it had less to do with not being able to swallow, and more of that when you can’t taste anything, it’s really hard to eat a ton of calories.
Your metabolic requirements go up. It’s 2,800 to 3,000 calories a day that you got to be taking in to meet the caloric needs to not lose weight. And doing that with eating ketogenic, and not being able to taste anything, that’s hard to do. So, I had a tube put in, a feeding tube put in. And John Weeks, John is a friend. I’ve known John for 20… I’ve listened to John for 30 years.
I’ve known him for 20 years. And he had head and neck cancer 10 years before me. And I just talked to him, and he helped guide Lisa and I. And he and Jeanie, they were there with us, and he helped me to understand how serious it was because I was still like, “I’m scheduled to go to China 10 days after I finished chemotherapy, yeah, that should be no problem. I’ll go to China for 10 days and teach.”
And he’s like, “No, that’s not going to happen. Your life is going to change.” And he helped me. And he helped me with understanding about getting a feeding tube. It ended up because I did so well, that I didn’t need it a lot. I used it a little. But I had very few side effects because of my perception, the ketogenic diet, the spiritual work that I did, and fasting before chemo, weekly chemo.
I think all those things really decreased my side-effect profile, and the doctors would be like, “You’re not acting like all of our other patients who come in here, who are getting chemo and radiation.” Then they knew what I was doing, but they’re like, “Maybe it’s related, maybe it’s not.” And I’m like, “I don’t know, who knows, maybe it is, maybe it’s not.”
But maybe if we share this with other patients, they’ll be outliers as well. As my friend in integrative oncologist, Nalini Chilkov, in Santa Monica said, “We want you to be the healthiest cancer patient that you can be.” And that was my goal. And there it is.
Dr. Kara Fitzgerald: So, I just wanted to say to folks that the list of responsive cancers comprises really the top cancers that we’re seeing. Probably, breast, colorectal, endometrial, glioblastoma, pancreatic, and then, you mentioned head and neck, and I said colorectal, you mentioned another cancer type.
Dr. Patrick Hanaway: Yeah.
Dr. Kara Fitzgerald: So, it’s a good chance that it’s-
Dr. Patrick Hanaway: Endometrial.
Dr. Kara Fitzgerald: … it’s going to be something that’s keto responsive. So, if you can talk about the mechanism of why the ketogenic diet is good. You’ve mentioned it a little bit. But there’s fasting, there’s full tilt water fasting, there’s Fasting Mimicking, there’s caloric restriction, or there’s actual isocaloric ketogenic. And can you just talk about what you did, and how you came to that, and any comments you want to make on the others, and what you think?
Dr. Patrick Hanaway: Sure. Well, let’s differentiate two pieces. One is the overall dietary approach of which a ketogenic approach, which is working on a diet that is going to be as you know, 80%, 85% fat, 10% to 15% protein, low carbs, measuring BHBs, beta-hydroxybutyrate, and being able to move into, during that period of time, nutritional ketosis, BHBs of 0.8 to 2.0 and being in that range. That’s the ketogenic diet. And that’s the approach. And that’s an important basis.
Dr. Kara Fitzgerald: And what’s your sugar at that time?
Dr. Patrick Hanaway: Well, what’s fascinating like wearing a continuous glucose monitor, my sugars were 90 to 100. And they never change over the course of the day. In fact, they were highest when I woke up in the morning, they’d be 98 or 99. And then, they just wouldn’t move through the whole day, varying less than 10 points, almost never going over 100, even when I ate.
In ketosis and hemoglobin A1c, which started at 5.7 and finished at 5.0, through the process of it. So, what we see with a ketogenic diet is that we’re moving through beta oxidation, we’re working with the fatty acid input into the Krebs cycle rather than carbs. And we don’t want to have too much protein because protein can actually move as excess protein.
The people who think paleo means I’m going to eat 50% protein. No, that’s not going to allow you to be in ketosis. So, when I work clinically, the answer is looking at your BHB. If your beta-hydroxybutyrate is in ketosis, then you’re doing it right. If it’s not, you’re not doing it right, and let’s figure out why. And so, what we find is that the Warburg effect, where there is aerobic glycolysis.
There’s plenty of oxygen around, but the cancer cells are choosing to use glucose to break down rather than the oxidative phosphorylation pathway. And so, that’s an awareness that we have since Otto Warburg discovered that in 1924. But we’re seeing that we want to lower the insulin levels. We want to increase the fatty acid levels. We want to reduce lactate concentrations because that’s going to slow tumor progression.
And we find that the beta-hydroxybutyrate is going to decrease inflammation. It’s going to have an effect on improving innate immunity. It’s going to decrease insulin and IGF-1, the number of pathways that we can see this move through. IGF-1, insulin-like growth factor-1 and insulin are going to stimulate proliferation and growth. And that when we reduce those, they’re going to change that.
There’s going to be normal apoptosis and cell death that happens. And so, this is part of what we’re trying to do with a ketogenic approach. And Dom D’Agostino, and Tom Seyfried, and Nasha Winters talk about this really eloquently in their books, and they can go into the details of it. And that’s one aspect of it. And then, the other aspect that especially as I’ve had, cancer patients since this time that I’ve focused on.
I’ve also talked about what happens with fasting before chemotherapy, which is a different aspect. So, first, ketogenic for cancer, we know what we’re doing is we’re recognizing that the tumor cells, cancer cells are going to have mitochondrial abnormalities. And they’re not going to be able to use glucose, and oxidative phosphorylation in the normal way.
They’re actually modifying the way in which they do that. And so, we’re leveraging that and saying, “Okay, let’s don’t go there. Let’s don’t give them glucose. Let’s don’t give them insulin. Let’s don’t give them insulin potentiation. Let’s don’t give them IGF-1 elevations. Let’s starve them in that way. “That’s the ketogenic approach.
Now, in terms of when we start talking about fasting, fasting is a different aspect in Valter Longo’s work, which started. Now, we’re talking about ProLon, Fasting Mimicking diet, and roles in relationship to cardiometabolic syndrome, and diabetes, and some cool new data on multiple sclerosis, and autoimmune disease. But originally, it was built around chemotherapy.
And saying, “Hey, can we actually create a differential stress resistance that’s going on?” Can we move in a way in which what we’re doing is we’re limiting the amount of substrate of glucose that’s available, so that the cells, let’s say the cells of the gastrointestinal tract, the mucosa that turn over three to seven days, they are going to move into a relatively more dormant state, we’re going to give a chemotherapeutic agent, which is going to attack the most fastest growing cells.
And the cancer cells are going to be more susceptible, and the other cells are going to be less susceptible. And that’s what’s talked about as the differential stress response. And so, that process is what their original research in mice was based upon. And then, they did some fasting studies that were published in 2009, and then carry them forward.
So, what’s happening in the process of fasting is that there’s less glucose, and there’s less IGF-1. And now, we move through where autophagy normal cell death, the process of cleansing, which is altered in cancer actually begins to work more effectively. And we see then that chemotherapy, which is going to have an effect on creating DNA damage, and increased reactive oxygen species, that is now actually able to be effectively stimulated, and there is going to be more DNA damage that is going to occur for the cancer cells that are going on.
So, now, we see that in the cancer cells, in the tumor environment, there is going to be an increase in autophagy, and we see that the overall increased sensitization to the chemotherapeutic agents, and then the tumor microenvironment, we’re going to see an increased cell death. But we’re also going to see a decrease in the adverse effects that happen on the normal cells that are going on.
There’s reduced glucose, there’s the reduced substrate, there’s reduced food, decreased availability. And so, we have VEGF, and IGF-1, and insulin all going down at the time of chemotherapy happening. And so, the delta between the adverse events to the normal cells, and the toxic effects to the cancer cells are all happening at that time. And so, we’ve seen studies that started in 2009, and that have carried through now into the studies in 2015.
And even a recent study that just came out in Nature Communications just last month that was looking at a fasting mimicking diet for neoadjuvant chemotherapy for breast cancer. And what we find is that the patients who are able to move through, and to fast, and in this case, 24 to 48 hours, there’s a little better effect at 48, but clearly an effect that 24 hours beforehand, and during chemotherapy.
When we talk about fasting, we’re talking about 200 calories. We’re talking about very limited caloric intake, bone broths, et cetera. And that those patients have decreased adverse effects, and increased DNA damage that is done to the cancer cells. Now, we’re not going to have the long-term effects on that. But if we’re able to move through chemo, and be able to do it in a way where it is not having the same adverse effects, which happened for me, that’s a huge win.
And as we do that, what we’re also doing is we’re encouraging no use of prednisone, no use of steroids because we don’t want to have that counterregulatory effect of driving up glucose in the same way. And so, as we do that, and there’s some good studies that have been done to be able to demonstrate this.
And the oncologist would say, “Well, that’s a nice idea, but no one’s going to do it.” And I say, “Well, what if we let the patients try it?” And we find that in the studies that these patients are doing this, I got a patient right now who is at 28 weeks pregnant with a Stage II plus breast cancer, who is getting chemo at this point in time, while she’s pregnant, and she’s moving through fasting before her Q3 week chemotherapy.
And she’s doing without steroids, and she’s feeling good. Or the patient that someone, a colleague, a friend of ours reached out to me, and said they had a patient with a Stage IV colorectal cancer, and he’s moving through the chemo. And he’s been doing a ketogenic diet, and fasting before chemo, and his five-centimeter tumor mass is now mucosal thickening.
And they may not have to do a surgical resection of the whole thing. It’s like, there are some really cool things that these are opportunities, let’s give people the choices that they wanted to. And if we could just decrease the adverse events, and the toxic effects of the chemo, and we can optimize it, and have the healthiest patients there. That’s a good thing. Let’s do that. Yeah.
Dr. Kara Fitzgerald: Extraordinary. Right, right, right. Rather than, of course, not just the glucocorticoids, but the sugary snacks that are shuttled around, right?
Dr. Patrick Hanaway: Oh my. Stunning, stunning to see the little crackers, and the six-ounce cans of Coca Cola and Sprite to help you during your chemotherapy. Oh my God, that’s just so misunderstood.
Dr. Kara Fitzgerald: So, it’s just profoundly misunderstood. They’re just toxins. Just listening to your story, and thinking about them, I shudder. It’s just so, so, so wrong. Okay. So, you did a full keto diet, achieving, I know you use a Keto-Mojo meter, and you wanted to maintain somewhere between 0.8 and 2.5. And that was between your rounds of chemotherapy. And then, for your chemotherapy, you would do a full fast, where you would consume around 200 or less of a good bone broth for-
Dr. Patrick Hanaway: And take exogenous ketones.
Dr. Kara Fitzgerald: And you took, oh good, okay, good. I was going to ask that.
Dr. Patrick Hanaway: I talked with Dom about it, and would take exogenous ketones on the day chemotherapy-
Dr. Kara Fitzgerald: Can you just tell me-
Dr. Patrick Hanaway: … nasty, hard to take, but it’s like, “Okay, I’m going to do it.” And so, my ketone levels would get up into the fours, four, 4.5, 4.8 while I was doing chemo, as a means of trying to accelerate the process. I used a couple products, one that Dom mentioned that name I can’t recall, and a Metagenics product that were exogenous ketones. So, it just helped stimulate the process alone.
Dr. Kara Fitzgerald: Is there evidence for that?
Dr. Patrick Hanaway: No.
Dr. Kara Fitzgerald: Okay. It’s theoretical, but okay, but why not? And other than-
Dr. Patrick Hanaway: Not that I’m aware of. I’ll just say it that way. There may be, but not that I’m aware of. It’s like, “Well, let me do the best I can.”
Dr. Kara Fitzgerald: Absolutely.
Dr. Patrick Hanaway: And we know that there’s basically no sugars around for the cancer during that particular period of time.
Dr. Kara Fitzgerald: Yeah. No, it absolutely makes sense. And then, you’re providing energy elsewhere, because your only intake, you’re consuming 200 calories. So, basically, it was food for your healthy cells, the exogenous ketones. Yeah. All right. So, that was your core program, the inner work that you started, and the foundation, and your connection with your family, and this was your core approach initially.
And then, you just talking about tube feed. You didn’t have to do that a whole lot, but I do recall you talking about the formulas that you guys had to invent. I think first of all, maybe some of the things Lisa made that you needed to actually take orally, but then you moved to feed tube. Yeah, yeah. Just quickly, I’m just curious what you were dumping in your-
Dr. Patrick Hanaway: Sardines, you start putting sardines in the Vitamix, and then trying to get them liquefied enough to be able to put them through a narrow bore feeding tube, a J-tube. And I had to warm them up, and get them liquefied enough to be able to get in. And it has to be like okay, they got to get in, in 10 minutes, otherwise they’ll start to cool down, and start to solidify.
And it was crazy at that point in time, but there are no good off the shelf ketogenic nutritional support. So, I’ve got some patients who have cerebral palsy, who have recurrent aspiration, and have J-tubes, and work with them, and work with products like Liquid Hope, and Kate Farms, and stuff like that. And they’re just not really the best products that we’ve seen.
End up having like what I’m just looking at them right here, like 36% carbs, the best products, or 19% protein, 36% carbs, 45% fats. And so, you’re not anywhere near ketosis that way. So, you got to really make them, and create them yourself, and be able to do that. And so, we did, and that was just part of the experiment in the journey along the way.
And then, well, I do want to touch on the other kinds of nutritional support. The questions that come in that say, “Well, you use antioxidants, what’s the role?” And we took a pretty conservative approach where it’s funny because I’ve pushed against this for a long time. And I think that really, the whole foods approach is a key aspect, and I’m never going to tell people to not eat vegetables and whole foods because of any concern for antioxidants.
But we were relatively limited antioxidants along the way, but did a lot of immune support. And then, as soon as the chemo and radiation therapy were over, then moved into greater antioxidant support with a number of different, both plant-based antioxidants, as well as some of the new tocotrienols, and things of that nature.
And worked with Nalini Chilkov, who’s an acupuncturist in training, but has been working in the integrative oncology space for 30 years. And she was super helpful for me in being able to create some discernment and help to give me the kinds of nutritional support that I needed in terms of different kinds of supplements along the way.
Dr. Kara Fitzgerald: So, what were some of the heavy lifters? What were some of the key supplements you used during chemo and then after?
Dr. Patrick Hanaway: Mushrooms were a huge piece early on, and throughout the chemotherapy and afterwards. So, working with Chaga, Lion’s Mane, Maitake, Reishi, some of the Stamets products, great, great tools for helping the immune system to be able to unmask working. I’m trying to think through the various components, I was going to put my list right in front of me, and I don’t have it.
Dr. Kara Fitzgerald: You know what? You can just ping me with it, and I can pop it on the show notes. People would love any, whatever, if anything comes to mind.
Dr. Patrick Hanaway: Sure. Yeah. No, I’ll just give you what Nalini’s recommendations were.
Dr. Kara Fitzgerald: Okay. Perfect.
Dr. Patrick Hanaway: And basically, I followed it, I followed the whole thing. I was to a point where I was taking 60 pills a day, and there’s fish oils, and there’s curcuminoids, and there’s the mushroom-based products. And then, later on moving into more antioxidant approaches, and higher doses of Vitamin D, and all the usual suspects. But being able to support methylation along the way.
Each of these things, some of them driven by specific nutritional testing, like a Nutreval, and being able to look at IGF-1 and TGF-B1, and what’s going on, and looking at D-dimers. And being able to deeply understand the nutritional physiology, and have targeted nutritional therapeutics. That was an important part of it as it has been in my career, and the way in which I approach patients.
It’s not one size fits all. We both recognize that you go to the store, the one size fits all, it really doesn’t fit anybody. No one looks good in it. But the one size that is for you, the personalization. So, foundational nutrients would include, obviously, as I said, the mushrooms, and omega-3s, and magnesium, and Vitamin D, and honokiol, which is a Chinese magnolia bark was something.
Worked with butyrate to help with the gut, and being able to store that, work with that. High, high doses of resveratrol, not the kind that you get from capsules, but using powders to be taking three grams of resveratrol a couple times a day. Generally, when you’re getting a resveratrol product, you’re going to get 200 milligrams of it, and you might take a couple of them three times a day.
But I was taking upwards of three to six grams of resveratrol a day. One of the questions you asked of me in the whole insulin resistance thing, and I looked at, and I started taking Metformin. And it’s like, “Okay, I can do this. I’ve seen the data. I’ve looked at it. This is a good thing to take.” And I started taking Metformin. And I went quickly from 500 to 1,000 milligrams a day.
And then, 1,000 milligrams, all of a sudden, on the third day, I’m like, I got diarrhea. I’m not tolerating this. Oh, this is the only thing I’ve changed. So, I stopped it and it went away. And I started again, and it came back. And I’m like, “Oh, man, this is… I’ve given this to patients for so long. And for me, it really had a negative effect, and I wasn’t able to tolerate it.”
So, then I moved into taking berberine. And taking that 1,000 milligrams three times a day, and that, I was able to tolerate really well. So, not only does it have some microbial effect, some gut microbial effect, but also the insulin sensitization affect it has. It was the reason why I was taking that. So, those were the main things, and then I also took, she recommended and is knowledgeable in some Chinese herbs.
That would include sclera, andrographis, astragalus, all immune-stimulating things. We probably think of them more now from their effect on COVID. But all of them, very effective. And so, I took an anti-inflammatory immune support protocol around that. And also, took a lot of red root. I don’t know how to say the panicle name for red root, but I was taking that specifically to be able to support my blood and my white count. And then, since that-
Dr. Kara Fitzgerald: How was your blood? How are your numbers?
Dr. Patrick Hanaway: Actually, my white count is still low, a year and a half out with a white count of 3.1. But looking at the neutrophil-lymphocyte ratio, and being able to optimize that, my hemoglobin went down to about 32, or hematocrit down to 32 at one point in time. But has come back okay, and it’s been supported in that way, and been looking at copper chelation therapy needed to get the red count back sufficiently before beginning a copper chelation approach.
And then, also, using approaches like what might be called a pulse therapy quarterly that works at artemisinin, IV vitamin C. Those are the things that I really focused on. We talked about IV curcumin and chose not to do that. So, really, focusing more on a scavenging therapy every three months with Vitamin C and artemisinin to do that.
The other thing I wanted to speak about before and I said we could talk about this for hours, but I was also really aware that if this didn’t work, I might need to use some immunotherapy. And one of the fascinating things in talking with one of the docs from Johns Hopkins, who has been working on this is that it’s pretty clear that the immunotherapy is going to be impacted by what’s happening with the gut microbiome.
And so, how do you optimize the gut microbiome to be able to deal with these immune checkpoint inhibitors? Whether it’s PD-1 or CTLA-4, and how to be able to ensure that whatever I’m doing, I’m actually working to optimize the diversity in my microbiome. And being able to have that, and we’re beginning to really understand exactly what those interrelationships are.
And it’s partly where in my big view of looking at meta genomics, and how we work with the gut microbiome, and we can see that increasing akkermansia, increasing bacteroides, increasing the Faecalibacterium prausnitzii, working with decreasing the bacteroidetes. These things are all very, very useful to optimize the microbiome in terms of being able to be activated properly for immunotherapy.
And if you have an altered microbiome, and you don’t have the diversity, and you don’t have those things, you’re at an effect where you’re going to have a decrease in the responsiveness, and an increase in the toxicity of the immunotherapies. So, I found that just really fascinating because it again, connects back to well, the diet, and nutrition, and what’s going on, and how you deal with cancer therapy.
So, I think that we were probably both at a presentation by Siddhartha Mukherjee at PLMI back where he was really beginning to understand the interrelationship between chemotherapy, immunotherapy, and nutrition. And it was really cool to be able to hear someone who’s at the top of his game, recognizing, oh my gosh, the nutritional aspects, and what’s going on with the microbiome have everything to do with how these medications work. And I was like, “Oh, yeah. Okay.”
Dr. Kara Fitzgerald: And he’s been studying it, he’s been studying ketogenic diet. Has he published on it? I know he had at least one trial going.
Dr. Patrick Hanaway: He hasn’t. He’s got a trial going on. So, the Tibetans like to say this I’ve heard, so this I’ve heard. I haven’t heard it from him. But what I was told was that he was trying to put together a research protocol that was looking at a ketogenic diet, and fasting, and immunotherapy. And each of those aspects, and NIH said like, “There’s no basis for this.” And so, he crowdsourced it, and worked to get funding that way for a protocol, a research project that he’s working on right now.
Dr. Kara Fitzgerald: That’s extraordinary.
Dr. Patrick Hanaway: So, I think it’s so cool that we’re seeing that the systems-based approaches that we do with functional medicine, with taking the big picture, with looking at biological plausibility, and how do we optimize the benefit, and minimize the risk to individualize therapies. Actually, whoa, it makes a difference. And so, now I’ve had a number of patients who have come to me since I went back into practice that have said, “Hey, can you help me with cancer?”
And it’s like, “Look, I’m not an oncologist. And I can’t help you to pick out you know which chemotherapy is best for you. That’s not my skill set. But how about if we work to make you the healthiest person possible going through however you choose to go through your treatment approach?” And I’m seeing some pretty amazing things happening with-
Dr. Kara Fitzgerald: Man, that’s so just very, very inspiring. We need to remember to just ping Jeff Bland to see if he can ask Siddhartha Mukherjee to come back, and speak again at PLMI. It’s just very exciting. Okay. So, I want to fill in some gaps, and then we’re on the homestretch. But I just have a couple questions. What were you attempting to achieve with the three grams of resveratrol, the mechanism?
Dr. Patrick Hanaway: I’m going to have to refer to Nalini around that.
Dr. Kara Fitzgerald: Okay, no problem.
Dr. Patrick Hanaway: Because that was done after I finished my chemo and radiation therapy. And so, that was really focusing on a super potent antioxidant effect.
Dr. Kara Fitzgerald: Yeah. Yeah, yeah. Well, let me tell you, as you know, I’m interested in DNA methylation and of course, the tumor suppressor genes are all hyper methylated. And we colloquial talk, we talked about these flavonoids as being methylation adaptogens, which is a term coined by Michael Stone.
Okay. As you know him, I’ll give him credit for that. But resveratrol is one of those wunderkinds. And so, it makes sense from that hat just because I’ve been in that hat. But okay, so that’s question one. Question two is, copper therapy. So, it’s high in certain-
Dr. Patrick Hanaway: Copper chelation therapy.
Dr. Kara Fitzgerald: Chelation for high copper. And so, I just wanted you to fill it in. It’s high, specifically in laryngeal cancers, correct? And others.
Dr. Patrick Hanaway: It can be. But really, the thing is, is that copper acts as an agent that stimulates angiogenesis. Angiogenesis, new blood vessel formation. Well, that’s what cancers need to be able to grow, to be able to metastasize, to be able to move beyond what’s there. And so, we’re looking at the copper-zinc ratio all the time. So, we’re going to use zinc, and that’s going to be an important component to keep that copper-zinc ratio in a good place.
We’re going to look at ceruloplasmin levels, which is going to be what your copper stores are. And we’re going to want to keep your circulating copper levels. That’s going to be your, gosh, I have to look back and look. I think it’s the plasma-copper levels in the lowest quartile, and your ceruloplasmin levels in the lowest quartile, and your zinc-copper levels as high as you can get them.
Dr. Kara Fitzgerald: And so, you are able to do that without having to actually chelate out, copper.
Dr. Patrick Hanaway: Well, I did that initially through the whole process by focusing on zinc, which can’t actually start oral copper chelation until you have your red blood cell levels or your hemoglobin, meaning, your hematocrit doing well. Because copper chelation will cause anemia. And so, you’ve got to actually have, and it took me almost a year to be able to get my levels up to a point where I could even consider copper chelation.
Dr. Kara Fitzgerald: But do you need to? Is your zinc-copper ratio such that you’re thinking about it or is it preventative? Yeah, go ahead.
Dr. Patrick Hanaway: It’s preventative. Mine is doing really well. The data, Dwight McKee, who was one of the grandfathers in the whole integrative oncology field would say that if we can work to prevent a recurrence, in this case, in the head and neck cancer. If we can prevent a recurrence for three years, then we can feel pretty safe that there’s not going to be a recurrence that goes on.
Dr. Kara Fitzgerald: Got it.
Dr. Patrick Hanaway: So, using that kind of tool in the post chemotherapy once your H&H is high enough to be able to do oral copper chelation, and then it’s monitored, that that is a great tool to be able to help mitigate long-term risk.
Dr. Kara Fitzgerald: Got it. Okay. Okay. Perfect. All right. So, I’ve got two more questions for you. I want to know, just was this I want to know… well, I’m going to ask you both, and you can pick how you want to answer it. Was this hard? Was this protocol difficult for you to do? And what is your self-care structure today?
Dr. Patrick Hanaway: I’m going to actually say, for me, it wasn’t that hard because it’s like I don’t want to die. I’m not ready to die. That’s the choice. It’s like, “Okay, really? What? Am I willing to tube feed sardines? Am I willing to take in 57 or 63 capsules a day with the idea at 60 years old dying?” My father died of Stage IV cancer when he was 60 years old. That was 25 years ago. I don’t want that. So, was it hard? It wasn’t easy, but it was not… I’ve done way harder things.
Dr. Kara Fitzgerald: You got it.
Dr. Patrick Hanaway: Going to the Cleveland Clinic every three weeks a month from home for three years, that was harder.
Dr. Kara Fitzgerald: Yeah.
Dr. Patrick Hanaway: I was able to move through it. And then, what’s my self-care? We didn’t get into all the aspects around recognizing, and connecting to nature, and improving heart rate variability, and looking at that love to be able to talk about those things. Because that connects back to the training from the indigenous elders that I have about connecting to the divine natural world.
And that is necessary, and so that my self-care process is one of being able to reflect, spend time in nature, care for myself, not overdo it, and be able to really listen to what’s happening in the world. And I would say that’s hard actually. It’s easy to fall back into old patterns. You and I have not talked about this directly, but when COVID hit, and you recognized, and was asked to really step into help us understand this, and we did the same thing.
Like, “Okay, now I’m focusing not on myself at all.” And in caring for others, I do that. But I found myself all of a sudden spending 40 to 50 hours a week on COVID. And where was I taking care of myself? I lost it. I forgot again. And so, I had to remember. I had to come back and remember. “Oh, no, I need to take care of myself. Because this is a long game. It’s a marathon. It’s not a sprint.” And yeah, so that’s the journey that I continue to be on.
Dr. Kara Fitzgerald: Wow, and there’s a lot of very shiny objects in our field. There’s a lot to-
Dr. Patrick Hanaway: Squirrel, squirrel
Dr. Kara Fitzgerald: Yeah, right? There’s just a lot to do, and you’re so passionate, and engaged. I can see in having a hard stop to engage in self-care, it takes a certain kind of a discipline. But actually, I saw you right before COVID. I saw you in February, and of course, you were glowing, and you just have this crown around you the whole time practically.
I got to connect with you a little bit, but because you’re just this… because of the transformation of what you had… the metamorphosis of your journey was just evident in everything, and just everything about you. So, I’m really glad that I got to be with you, even if it was just in the wave of your energy, as you pass by. That’s fine. I know I got to give you a hug, and we got to chat. I’m teasing you, but-
Dr. Patrick Hanaway: Yeah, I know, but I wouldn’t wish this on anyone. And it’s been one of the biggest blessings in my life. You can’t see that going into it on the frontend. But we’re all asked to… we have challenges in our life, and we have struggles. And it’s not as though we’re trying to avoid the struggle. It’s how we move through the struggles that defines who we are, and how we relate, and connect in the world.
And that’s the opportunity, and functional medicine has been cast on the anvil of adversity. And there’s something really here. And it continues to be shown that the ways in which we approach with thoughtfulness, with open hearts, with looking at science, and with working to personalize the approach, in a way that that looks at a big picture view at a systems approach to individuals.
Whatever disease they have is a way that is of benefit. And you and I are both blessed to be on this curve where we get to share that with people. And the people who come to see us are people who are saying, “I’m not satisfied with the way it’s been offered so far. Do you have something else to be able to give?” And it doesn’t mean that it’s going to apply for everyone in every circumstance.
But in those patients who are looking for transformation, and change, and support on that journey, that’s what our roles are. And we have this incredible opportunity to be able to do that. And I’m just deeply appreciative of that, and appreciative of the mentors that both you and I have had, whether it’s Richard, or Andy, or Jeff, or David, or Michael or Mark, and Sid and Leo, and many others along the way, and we continue to grow and learn.
Dr. Kara Fitzgerald: Yeah. Well, Dr. Patrick Hanaway, I love you. I adore you. You’re an inspiration. You are a bright light. Your honesty, your willingness to just give this podcast, it’s just been really, really fabulous. And I look forward to putting it out there into the world. I think it’s going to be quite meaningful for clinicians, and just regular people as well.
Dr. Patrick Hanaway: Thank you.
Dr. Kara Fitzgerald: You’re a bright light. And so, thank you.
Dr. Patrick Hanaway: Well, I have one request.
Dr. Kara Fitzgerald: Yes.
Dr. Patrick Hanaway: And that is give Queen Isabella a big hug.
Dr. Kara Fitzgerald: I will indeed. Oh my God, I will indeed. And then, I’ll send you a couple of pics. Okay. Big hug to you.
Dr. Patrick Hanaway: Great.
Dr. Kara Fitzgerald: Thank you so much.
Dr. Patrick Hanaway: Thank you. Thank you, Kara.
Dr. Kara Fitzgerald: And that wraps up another amazing conversation with a great mind in functional medicine. I am so glad that you could join me. None of this would be possible, through the years, without our generous, wonderful sponsors, including Integrative Therapeutics, Metagenics, and Biotics. These are companies that I trust, and I use with my patients, every single day. Visit them at IntegativePro.com, BioticsResearch.com, and Metagenics.com. Please tell them that I sent you and thank them for making New Frontiers in Functional Medicine possible.
And one more thing? Leave a review and a thumbs-up on iTunes or Soundcloud or wherever you’re hearing my voice. These kinds of comments will promote New Frontiers in Functional Medicine getting the word on functional medicine out there to greater community. And for that, I thank you.
PATRICK HANAWAY, MD is a board-certified family physician trained at Washington University. Dr. Hanaway served on the Executive Committee for the American Board of Integrative Medicine and is Past President of the American Board of Integrative Holistic Medicine. For more than 20 years he was worked with his wife, Dr. Lisa Lichtig, in clinical practice @ Family to Family: Your Home for Whole Health Care in Asheville, NC.
After 10 years as Chief Medical Officer at Genova Diagnostics, Dr. Hanaway became the Chief Medical Education Officer for the Institute for Functional Medicine (IFM) where he oversaw the development and implementation of IFM’s programs worldwide. He has taught with IFM since 2005 and fills numerous roles: leading the GI Advanced Practice Module, Co-Chair of IFM’s Expert Advisory Board, leading the COVID-19 Task Force and serving as a Senior Advisor to the CEO.
In 2014, Dr. Hanaway worked with Dr. Mark Hyman to develop the collaboration between IFM and the Cleveland Clinic, where he was the founding Medical Director, then Research Director. He now serves as a Research Collaborator with the Cleveland Clinic Center for Functional Medicine. His research interests focus on nutrition, the microbiome, and evaluating value in functional medicine models of care.
In 2018, Dr. Hanaway was diagnosed with Stage IV Laryngeal Cancer. His life has been transformed through a functional and integrative approach including nutrition, shamanic healing, acupuncture, herbs, prayer, chemotherapy, radiation therapy, community support, spending time in nature and love. Recent medical assessments demonstrate ‘No Evidence of Disease’. . . and life continues to be filled with uncertainty.
The primary focus of Dr. Hanaway’s work is to leverage his skills and knowledge to transform medical practice, through education, research and clinical care.
Importantly, Dr. Hanaway was initiated in 2009 as a Mara’akame [indigenous healer] by the Huichol people of the Sierra Madres in Mexico. He holds community fires, leads ceremonies and offers traditional healing sessions.
Keto for Cancer (book), by Miriam Kalamian, EdM, MS, CNS
Tripping over the Truth (book), by Travis Christofferson, MS
New Frontiers podcast with Dr. Thomas Seyfried: Cancer as a Mitochondrial Metabolic Disease & The Calorie-Restricted Ketogenic Diet
Keto for Cancer (book), by Miriam Kalamian, EdM, MS, CNS
JAMA publication: Association of the Functional Medicine Model of Care With Patient-Reported Health-Related Quality-of-Life Outcomes
DrKF FxMed Resources
Clinician Professional Development: DrKF FxMed Clinic Immersion