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Robin Daly
Hello, welcome to the Yes To Life show. My name is Robin Daly and as well as being the regular host for this show, I’m also the founder of Yes To Life, the UK’s integrative cancer care charity. If you want to find out more about integrative medicine or what Yes To Life does, then please do visit our website which is yestolife.org.uk. One of the most exciting developments in the last five or more years has been the rise in interest and adoption of repurposed drugs, drugs developed for other purposes that have been found to be useful to those with cancer. Jane McClelland has been majorly instrumental in raising awareness of the potential of these drugs as part of her approach to starving cancer metabolically, but key to implementing them has been the Care Oncology Clinic in London, which has been working now with a programme of adjunctive treatment built around four of the most effective and safe drugs in this class. Today, I’m speaking to Dr Hariharan Kuhan, one of the consultants at Care Oncology over the internet. Hi Hari, a big welcome to the Yes To Life show.

Dr Hariharan Kuhan
Thank you so much, Robin. Thank you so much for having me.

Robin Daly
It’s an absolute pleasure to have you to be our guest for this week’s show. Of course yes to life has featured the groundbreaking work of the Care Oncology Clinic before but this is the first time you and I have talked and as quite a bit of water has gone under the bridge since we last featured the clinic I’m looking forward to catching up on developments. So one of the very exciting aspects of repurposing drugs for me is the way that they occupy this middle territory between the traditionally warring factions of orthodox and alternative oncology which could equally well be characterized as genetic and metabolic in the ways that they view cancer. Repurposed drugs are largely seen as metabolic approaches to cancer treatment but they’re nonetheless they’re the products of the pharmaceutical companies who are working almost exclusively in the genetic paradigm. Unfortunately for you guys this does seem to mean getting shot at from both directions. Do you want to say a little bit about this middle territory you’re in?

Dr Hariharan Kuhan
Absolutely, Robin, you’re quite right. You hit the nail on the head there. So I often sort of feel like I’m walking the line in between, of course, the simple, the typical conventional paradigm and, and anything else really, you know, whatever the label is for anything else by the conventional doctors. You know, I think I see this as an opportunity to draw from both sides, to be honest with you and draw the positives from one side. Yes, there are the negatives the pharmaceutical put together. And of course, the way we execute conventional practices and protocols. And one could argue that there are problems on the other side with the lack of maybe evidence based in the typical conventional setting. I’m lucky to have the opportunity to walk the line, to be able to draw from both sides and often that’s what I witnessed in the patient cohort that I end up meeting. Those of course who are, you know, brave enough to go via the the conventional route and of course accept the treatments given to them and offered to them by the conventional doctors and then those that have that little bit extra the proactive nature to want to try and do more for themselves and who are brave enough to sort of, you know, try and ride the tide of information that exists and formulate a way forward to incorporate other measures whether they be supplements or integrative therapies or nutritional aspects to to try to fight the disease or aim for better. The way I see it, I guess I’ve learned a lot in my role in this clinic as a full time lead to sort of observe and learn the caveats, the pros, the cons, the things that can be a sort of access from both sides and trying to navigate a sort of a midline if you like down the middle where we can indeed do something in a safe and meaningful way because often in the space that we work with care oncology clinic. As you can imagine, we meet patients from all walks of life with different types of cancers and different backgrounds and facing different treatment options in the conventional sense, etc. So, you know, with all of that bearing in mind, you know, we have to be very mindful of the risk of interaction, particularly with medicines and the conventional treatments and the various lists of supplements. It is a very nuanced sort of space to work in. And I think you know any integrative practitioner will probably agree as well they often have to face a patient with a long list of supplements or even provide a patient with a long list of supplements and being cautious and careful about the aspects of pharmacogenetics and the way of course the genetic metabolism polymorphisms affect the way drugs are even broken down. So I think, you know, in a way, it’s a very simplistic sort of approach to this and trying to approach this in this field of repurposing medicines and a very straightforward protocol, but there are so many different sort of nuances to be taken into consideration. But certainly to your question, Robin, I mean, it is about trying to draw from both sides of the fence and trying to walk the line and find a safe way forward and a meaningful way forward to always just aim for better whatever better means.

Robin Daly
Yeah it’s very interesting your position because in a way most of the integrative practitioners are kind of on the outside trying to push their way into the system but you’re in a way you’re spun off out of the system aren’t you and coming in a different direction into the integrative space.

Dr Hariharan Kuhan
Exactly. And I find that fascinating as well. So because of my background being we’re training in conventional medical oncology, working, you know, with, you know, big names in central London, Marsden at St. The results from next generation sequencing or dealing with innovative new treatments in early phase clinical research and new immunotherapies and till or, you know, just sort of autologous sort of adaptive transfer therapies. So, you know, working in that environment and then coming into this space. It’s sort of it’s interesting because, of course, you’re right, because of that educated if you like, or culture of of not wanting to embrace anything else to them evolving into a situation. I think it’s more of an evolved state to say, hey, we don’t need to be fear mongering. We don’t need to be as afraid of these other things. Let me open my eyes and be less abrasive and think, okay, what is the contribution from these guys? Why are they doing so? Well, why are there esteemed societies? And why am I seeing, as I told you before, my LinkedIn page or my Facebook thing or my Instagram? Lots of fascinating research and developments in the space. You know, we should be working more in a collaborative effort to try and incorporate more. I always reflect back and I often tell my patients actually when they, you know, initially when I introduced myself as Dr. Harry Horan, my parents are Sri Lankan. And so I’m from a cultural Ayurveda, so Ayurvedic medicine. And so I grew up in a household with it. I didn’t believe in any of it being raised in the West often would, you know, have arguments with my dad. But how humbled I am now when you realize every patient, you know, considers turmeric or curcumin or ginger or garlic or black seed or the ashwagandha. And if you take the time to look at the data and the research around such things, you see that generational cultural knowledge. And that exists with so many different things. But my eyes were only open to that sort of the world is by just being prompted to have to do so by patients I was meeting who were asking me questions that I had no conventional training for. Interesting.

Robin Daly
Interesting. Well I think particularly because you’re dealing with repurposed drugs it’s very reassuring that you have come in that direction and you’ve come out of mainstream medicine because obviously these are quite potentially dangerous things to use but the interactions with all the treatments that people may be having is critical when you start using extra drugs. I mean it is with supplements as well but I think the safety issues are massive.

Dr Hariharan Kuhan
Absolutely, absolutely Robin. And that was the thing. And I guess that’s why I said part of when I when I do a consultation, I mean a patient for the first time. I introduced myself and mentioned my background because I want to give them some comfort that I have that knowledge base. And I think that’s that’s essential. I think if you’re ever talking to a cancer patient facing a tyrosine kinase inhibitor therapy or a pop inhibitor or an immunotherapy. It’s my business to fully understand that what I’m introducing into their repertoire has no bearing or negative connotations. If I can minimize that risk, then, of course, and that’s part of the education process. Of course, and you know, we do have extensive consultations where we go into depth about the individual medicines and their their their mechanisms. But also again, you know, we are reactive to the individual. So, for example, a patient will commonly ask, you know, do you apply the same thing is the same thing given to every patient and why. And the answer to that question is, well, you know, yeah, we use a cocktail of medicines that are essentially the same we draw from before. But the medicine dosing and the scheduling depends on the individual circumstances. It depends on the patient’s blood work, of course, their liver function and again the treatment they’re receiving. And of course, you know, because, for example, in the case of an immunotherapy. It’s not really appropriate to give someone high doses of doxycycline on a regular basis. There have been papers in the past that are shown by one from Imperial College. Pinato was the principal publisher. He proved that actually with patients who had had antibiotic courses prior to their immunotherapy. The outcomes were worse. It must be because the microbiome was being affected, you know, tying into everything that we talk about now in the space about the importance of microbiome. So you kind of think, okay, well, hell no. Let’s refrain from using regular doxycycline. Let’s stop that and let’s amend other doses, you know, in a gynecological cancer where we worry about the loss of P53 or we worry about angiogenesis, of course, methods, medicines such as Mevendozole or Vermox would be simply more relevant. So again, there are just these particular traits, you know, dependent on the individual and the treatments they’re receiving that we have to take into account. Liver function is one of the things I’m a big stickler about. I think we always have to be because the liver is what metabolizes medicines and supplements. And again, you know, part of our safety network includes that we do regular blood tests. So if a patient starts a protocol, we have their preceding bloods within the space of four weeks of commencing and then we repeat the bloods within four to six weeks on commencing. And then once again, every six weeks to make sure, you know, I spend most of my lunch times and after hours doing non billable phone calls with patients to try and ensure these open channels of communication, I believe, are so important because so many things happen in between reviews.

Dr Hariharan Kuhan
And this is one of the best things I can one of the satisfying things about my job now is that I’m really able to keep closed tabs and me and the doctors on the on the on the patients themselves. So email service, fantastic admin team, fantastic callback service, you know, you know, all of this connection in between the formal setup every eight to 12 weeks. Half have that in place to be able to respond and react quickly because of the sensitive positions that our patients are in. But yeah, it’s, you know, like to what you said, I mean, you know, this is it, we have to be ever so careful. And that’s why a detailed examination of the history, the medicine list, the supplement list, as I said, being open and having a safe space, a good forum for patients to openly talk to us, tell us of their concerns, keep in touch with us. There are patients, for example, will see a nutritionist, you know, or maybe another intricate practitioner. And of course, you know, because we kind of recommend open channels of communication and updates, they will come back to us and feedback to us about, you know, the things offered to them or, you know, advise to them. And then we’ll make sure again that they’re all safe and, you know, above board and it goes both ways as well.

Robin Daly
That’s brilliant. I mean, you know, that’s precisely what’s not happening in oncology wards is that basically most people don’t tell their oncologist because the oncologist gets angry about it. And so therefore they don’t know what is going on. So I mean, that’s ideal.

Dr Hariharan Kuhan
You wouldn’t believe like I, you know, again, a common question to me is, you know, what should I do about my consultant? Alright, so instinctively, my answer, the right thing to do is to be open and honest. And just, you know, you know, as a professional courtesy to someone prescribing you treatment, you should be able to openly tell them what you’re doing, please provide them with your clinic letter, etc. I’m more than willing to answer any questions or any concerns if there might be any, you know, we ultimately have to leave it down. It’s the right of the patient to decide. But I’ve heard, you know, a handful, you know, I’ve met, you know, a few, a fair few, maybe seven, 8000 patients now, but maybe four or five come to mind where a consultant just said to them, if you do anything else, I’m not going to treat you. Like, you know, and you think, Oh, my goodness, how could anyone ever be that that that be that horrible that abrasive?

Robin Daly
No, no, it’s quite, it’s something I’ve come across a lot. Yeah, so. Yeah. It is what it is, but. You know, grim.

Dr Hariharan Kuhan
We promote, you know, open honesty, open communication. You know, the decent consultant will say, look, I can’t agree. I can’t recommend what you’re doing. You know, it’s not my place too. And, you know, again, you know, I’m worried about your safety for a place of obviously caring for their patient’s safety, but let me run the medicines or the supplement list by my pharmacist to make sure there’s no concerns for interaction. And let’s go that way. But of course I understand if I was in your same position, I’d probably do a similar thing. So you get that kind of decency more often than not. But like I always say to patients, this is not appropriate. You should not be in some anxiety inducing situation because of anything that I’m doing with you. That’s completely not on. And that’s again, part of the reason why I always want to have open channels of communication to just talk to people if they have any concerns, you know, that are flagged up, or there’s some fear mongering and they just need someone, another voice to talk it out with. I’ll always offer that. We’ll always offer that. And we’ll always do our best for our patients because we need them to understand this as well. This is about education as well as just not just being a pharmacy where we just churn out a bunch of medicines. It’s a case of, I want them to be informed enough to understand and help these positive choices that’ll work towards a better outcome for them.

Robin Daly
Absolutely. Okay, so let’s just assume we’ve got some people listening here who have never heard of repurposed drugs, they’ve never heard of a care oncology. Just in the broadest terms, what are you offering and who are you offering it to? Excellent.

Dr Hariharan Kuhan
question. So, the Care Oncology Protocol is essentially a protocol of off-label or repurposed medicines well defined by researchers having a relevance in the anticancer setting. So, if you think about it, the idea of off-label medicines is a logical one. If we look at the thousands of medicines we have access to, we can find out through research and publications over the past 70, 80 years, those that have anticancer qualities. So, what we’re trying to do is just an evidence-based hunting, and actually there was a big study called the Redo Project, which identified 290 agents. We wanted to apply some logical criteria to a predefined list developed from the academic sort of school. Those logical criteria included things like, let’s pick the medicines of the most well-established and thoroughly published about in academic papers, not just the Petri dish experiments and the mice cells, but the human data, the population studies. We often say the triangulation of data to find the appropriate tools and weapons. Let’s pick the medicines that are the most, that are safe to use in combination with each other, i.e. wouldn’t interact negatively with each other. And those that are inert enough to not disrupt the conventional treatments, because it would be inexcusable of me to really nearly give a bunch of medicines, not giving a two-hoots to what else the patient was receiving. And add to that list, a low side-effect profile and medicine could be used safely in the community without requiring regular monitoring. Now, one of the big X marks the spot, and this is what you’ve obviously discussed in many talks and previously in recent, you know, recent on the weekend, is this idea of trying to affect cancer metabolism. So, if we very simplistically debate and discuss metabolism as being, you know, the ability of cancer cells to drag nutrition into themselves and create energy for growth division and spread via cellular processes to simplify things, that’s essentially what we’re trying to also target, trying to essentially affect the metabolite cascades and pathways to essentially make the cell weaker or destabilize it or more dysfunctional, therefore easy to detect by the immune system or slow down the processes, but essentially make it easier to kill, we can thereby aim for better. So, the point of the metabolic approach was really not to compete with anything, replace anything, say to people, take a bunch of GP drugs, don’t listen to your clever oncologist, it was the opposite. It was to say, do what you have to do, follow what feels right, follow the data, follow the safety, follow the evidence, do, you know, do your reading, inform yourself, but if we can get more weapons into the arena of cancer medicine as soon as possible, we can aim for better, we can aim for a more enhanced response to treatment, we can aim for a durable response to treatment, a maintenance of remission. Now, to the question of who? So, this, you know, in an ideal world, I would like this applied to anyone as soon as they’re diagnosed, because I truly believe as in observing things, ultimately, when is the metabolic approach going to be most effective?

Dr Hariharan Kuhan
Probably when the cancer is lower volume and probably when the cancer is relatively naive, I hasn’t met, you know, six or seven different lines of chemo involved into a different beast that’s hungry, that’s using all kinds of, you know, mechanisms and pathways. And obviously, you know, quick reference to Jane McClellan’s ideology of blocking all pathways, right? So, in an ideal world, that will be the great time to do it. And I’m starting to see more and more patients having just been diagnosed or in their first line of treatment. But we don’t really live in an ideal world. So, you know, one day we might get there. So, this is applicable to any situation. So, for me, and that’s what I meant when I said aim for better, I mean, aim for better. I mean, if we can use the metabolic approach to suppress metabolic syndromes, we can aim for a better outcome in all kinds of stages of cancer, we can try and quell the side effects and toxicities that can be augmented by the cancer treatments and caused by the cancer treatments chemo radiotherapy. Because of course, it’s a two-way street cancer chemotherapy radiotherapy can induce metabolic syndromes, okay? And at the same time, patients could have underlying metabolic syndromes. And again, again, I’ll just, you know, I’ll lead to a manifestation of greater side effects, for example. So, treating metabolic syndromes, which is the ambition of the protocol, which has slightly evolved, which I’ll tell you more about shortly, Robin. I mean, you know, it’s got to be beneficial in the grand sense of things that any patients that are either early on in their journey or in mid-treatment receiving chemo radiotherapy immunotherapy with a beauty just aiming for better, okay? So, it’s applicable to a wide stretch. Obviously, you know, when we assess patients, we have to take into account their blood work and things. So, of course, unfortunately, if there are patients whose liver function is very awful, if they’re malnourished or they have issues with their gastrointestinal system, the logistical issues there can may then affect, you know, enrollment into the protocol. But that’s why, again, there’s a very, you know, very clear sort of assessment sort of stage prior to enrolling patients in, whether we assess their performance, status, blood work, medical questionnaire, et cetera, to get a true feel whether we can tangibly get these medicines on board. The downside of the metabolic approach, even with medicines, I mean, we tend to say roughly the medicines take about two or three months to optimise in the body. You know, maybe supplements take a lot longer, maybe four to six months, but the medicines roughly two to three months. And because of the way we approach things, we start very cautiously at low doses, systematic escalation with blood test review and tolerability assessment. You know, we can’t go in gung-ho with high doses of metformin.

Dr Hariharan Kuhan
It just wouldn’t work. You know, there are like I kind of touched on that term, the pharmacogenetics side of things that you can meet a patient who it has the lowest dose of statin and has a neutropenia and elevated liver enzymes, which can have a knock-on effect to their treatment. So, we apply things quite cautiously, but because of the nature of the approach and the agents that we’re using, it can be a slight slow burner, you know, but that’s why, again, preferably if we can do this as early as possible one day in the future, if we could do it before the manifestation of disease, that would be amazing as well. You know, screen for metabolic dysfunction early, but, you know, one day, one day at a time.

Robin Daly
Right. Okay. Thank you for that. So, you know, when we were last talking to Dr. Ndaba Matsuboku, speaking for us, you were busy at work collecting up data for a paper which you published in 2019, I think. Do you want to tell us about what you found out, what you reported there?

Dr Hariharan Kuhan
Yeah, absolutely. So it was part of what we call the metric study. And it was a paper, essentially, which kind of expressed the process that we went through for collecting data for our study, the nuances, the problems, the issues with it. But also, really, it was a snapshot of data for our glioblastoma patients. So as you probably know, glioblastoma is a horrible, a horrible form of primary brain cancer, very fast growing, notoriously very difficult to treat. And generally, from large cohort studies that have been published in the field, the median survival time from diagnosis tended to be in the order of about 14 months, with conventional treatment, which typically involved what we call the STUPs protocol, where you have surgery, and then six weeks of adjuvant chemo plus radiotherapy, and then six months of adjuvant hemizolomide chemotherapy, something that hasn’t changed in quite a long time, maybe 70 odd years. So what we essentially did, we had just about 100, just roughly under 100 patients, and we followed them up between, I think it was a three year period. And, you know, essentially, what we found is that the median survival, by adding our protocol in combination with their chemo radiotherapy, was significantly increased to 27 months. And that was quite simply, yeah, a significant, as compared to the 14-15 months in other countries, it was published, double, right? So we’re always careful not to kind of go out and say, hey, we can double survival time because, you know, in such papers, there are, you know, when it’s not a randomized controlled trial, there are biases, there are compounding factors, but it was a signal that couldn’t be ignored. It’s a signal that couldn’t be ignored. And actually, we’ve been collecting data since that time and are looking to publish our follow up data. But I can tell you for free that the preliminary studies and review of the data has again validated that outcome. So the signal was so powerful, it just showed that even, you know, with a simple, with an aggressive cancer, with next to no real options, maybe two lines of treatment, typically the second line is something called Lamustine, by just adding the metabolic approach early on, as early as possible, in combination, adjunctively, not one or the other, but in combination, we could definitely aim for the better. And I’ve got, and it’s fascinating, you know, I’ve got, I’ve got some GBM glauvastoma patients that have been with us for five years going strong, you know, and I’ve got examples, and I know it’s a bit anecdotal of other patients with, you know, stage four cancers, who were given a death sentence and tell that they wouldn’t be here for a year here, you know, four or five years again, going strong. So, so, you know, the message that I learned from that with time, again, you know, it was, and again, being a data guy, like I know there are obviously different levels and standards of data, but, but you can’t ignore the successes when you see them, you know, and that’s why I often draw patients towards Jane’s Facebook forum to look for the positive.

Dr Hariharan Kuhan
I know it can be a bit chaotic, and sometimes people are overwhelmed, but the success stories are there and you need to draw from the sources of inspiration to be able to, you know, especially in the dark times to be able to try to get the energy to get up and read and learn and try and incorporate whatever you can, right?

Robin Daly
So can I ask these greatly extended lifetimes that you’re achieving, presumably for most of that period they’ve actually finished their mainstream treatment and they’re actually just on your protocol which you’re maybe adjusting along the way. So presumably it’s good quality life with not terrible side effects is that.

Dr Hariharan Kuhan
That’s one of the key things, a side effect profile, right? So we were able to confirm, I think, from that particular study over 85% of the patients tolerated all the protocol agents with no serious adverse events. And the nature of the medicines are such, as you know, probably, Robin, so their medicine metformin has been around for over 70 odd years. Statins have been around for over 60 odd years. Mabendazole is a children’s medicine, doxycycline used by GPs for all kinds of purposes for a very long time as well. So we know that a lot of these medicines can be used for long standing indications already. We’re a bit more cautious when it comes to doxycycline, to be honest. So after a two year mark, we may drop the doxycycline and use it a bit more sparingly. But historically, it’s used for years in acne in teenagers, or rosacea infections in adults. And even doxycycline can be used in colorectal cancer asioms in the NHS through the entirety of their 12 cycles of cetuximab, which is a monoclonal antibody that causes acne all over the face and the body. So that’s kind of the pathological approach, I mean, so often, I’ll put it to a patient. Well, if you had been a diabetic on metformin and you were on a statin prescribed by your GP and developed cancer and needed to have cancer treatment, your oncologist wouldn’t stop those drugs. Like they wouldn’t say, oh my gosh, the risk of interaction, I need to stop these things immediately. They wouldn’t care, they wouldn’t look at it twice. So it’s interesting when there’s sometimes a bit of fear mongering, you know? But that’s again, maybe the message being lost, the fact that we’re not just, again, just churning out a bunch of medicines willy-nilly, we are taking over into account the full situation, trying to be as safe as possible, as collaboratively as possible. And even then, you get the oncologist who says, oh, my patient’s ever so nauseous. And I said, well, that’s because you’re giving them chemotherapy. I’m sure it’s not the statin. I’m pretty sure it’s the chemotherapy that you’re giving them, right? So give them some anti sickness. So there are sometimes these silly little things that just happen, but we’re of the mindset, however, that the priority has to be the conventional treatment. So regardless of what I say in the joking, and you know, at the end of the day, we always try and stress that we’re all on the same page. Under the day, we have to follow the evidence base as much as I might knock the data. You know, everything we do in the public sector is based on the highest caliber of data, the right scientific method, growing conclusions in the right way. Yes, there’s not enough of it. Yes, there are finite solutions. Yes, I have a problem with that. Drug development is sluggish. You have to jump through various hurdles and inclusion and exclusion criteria to access medicines or innovative medicines. And that’s not always, you know, so it’s not always a no brainer or a win for everyone, but it’s the best thing we have. And so if that’s on the cards and that’s on the table, we can never do anything to interfere with that in the negative way.

Dr Hariharan Kuhan
So I always support patients in that regard, but that’s again, part of our process and why we do things very cautiously in a set price manner.

Robin Daly
It all makes sense. So it seems to me that there may be there’s a certain Trojan horse element in repurposed drugs, which is, as I said in my introduction, you could largely characterise orthodox medicine as being genetic medicine and other sorts of medicine outside of that being metabolic. And yeah, there’s no common sense that goes with repurposed drugs where you can say it’s anything genetic whatsoever. And so, in a way, I think there’s a feeling that if you open the door to saying, okay, well, maybe these work in some way, maybe they could help, then there’s a whole raft of other things which have been largely shunned for the last hundred years suddenly start to make sense, you know, like to do a diet for a start, you know, diet is like the worst possible thing, you know, don’t mention the diet. So, you know, I think that’s why there seems to be resistance to, I mean, these are, after all, just mainstream regular treatments you’re giving. I mean, it’s not like there’s a big deal, but it’s big.

Dr Hariharan Kuhan
I mean, you’re so right. Like, I think that’s hilarious because I mean, the diet thing, I mean, I, because it’s weirdly ingrained into us as well to just say, just just eat as you want, you know, you know, our own patient always telling me how pissed off she’d be, but she noticed that actually on a cancer ward, there’d be someone lovely lady with putting a trolley full of sweets. Yeah, that makes sense. That makes a lot of sense. And, and, you know, we, you know, it’s so it’s such a crucial part of this, this whole thing, you know, I, you know, I, one of the things I just wanted to mention, Robin, is, you know, with the, with the COC protocol, we’re actually, we’re actually evolving the protocol to actually incorporate a lot more. So one, you know, historically, what we would do is we would obviously based on the knowledge base that we had of the relevance of the medicines, you know, get the medicines on board, titrated to the individual, start cautiously, etc. Maybe in a similar way to chemo, you kind of tweak the dosing based on toxicities as you go along, but you start with a set dose. But we realized, you know, we’re actually delving into the research, you know, a couple of the doctors in the clinic kind of figured out there were some specific blood tests that we could do to give more insight into the metabolic well-being of an individual. So, you know, we talk a lot about insulin resistance. We talk a lot about, you know, the cortisol levels and the, the, the general cholesterol or fat states or saturated fat states in the body. So there are numbers and there are tests that we can do. So we kind of put together a package called COC plus moment, which will change in terms of its naming, but it’s, it’s aimed at doing those niche blood tests to get some biomarker data, some numerical values that give us true insight into the individual’s metabolic and inflammatory states, because it then allows for us to have a little bit more of a refined discussion tailored to the individual around those metabolic aspects, diet, exercise, stress, sleep, you know, all of these in parameters that are, you know, clearly, you know, again, in the integrative space, I’ve been known to be very, very important, but it’s certainly in terms of what we’re doing. Again, we can influence these markers alongside our prescription of medicines and whatnot, but a discussion around a few supplements, you know, you know, just again, a promotion of the importance of things like even vitamin D and omega three and the glucosamine, for example, you know, if we can use these numbers and numerical values to say, Hey, what about intermittent fasting and low glycemic index diets? And, you know, it with a doctor led kind of oversight thing, bearing in mind the whole situation and scenario in terms of the treatments they’re receiving. And I said, the malnutrition that can occur in the nutritional deficiencies with systemic treatment and all that, you know, so just catering to all those problems, but actually having an informed discussion about metabolic well-being as part of what we have to offer in terms of the repurpose medicines,

Dr Hariharan Kuhan
because we truly believe in this being a multifaceted approach, not a, you know, a multi-pronged approach, not a one hit wonder situation where you put all your eggs in one basket. That’s what we’re trying to move away from. We’re trying to move away from the ideology that, yes, you can have a surgery and chemo. And that’s it. That’s good. That’s your lot. You’re cured forever. It’s all fine. We’re trying to say, look, this is a chronic disease. So we should reform in the same way. I’d treat you if you had had a heart attack, if you had a heart attack, I’d be banging on the door and saying, reduce your stress levels. My friend exercise more, you know, go for a run 30 to 60 minutes a day aerobic exercise, get in some fasting, watch that belly, watch that gut, you know, some just to have that conversation. And we don’t do that. We don’t do that with cancer patients. And, you know, and, you know, it’s such a vital part of it all.

Robin Daly
No. I’m very pleased to hear you say it. I mean it’s fantastic. Once you’ve embraced the concept of cancer being a metabolic disease that you can influence in that way then of course all these things do start to make sense, complete sense and this is not noticeable just the absence of advice in that area. It’s the kind of outright rejection of it. I had a call from somebody last week who has just started immunotherapy for melanoma and he asked about his diet and he was told oh no we don’t do diet here as long as you don’t waste away we’re not bothered. Now it’s absolute common huge public knowledge that the state of your gut profoundly influences whether the treatment succeeds or not. So that’s thoroughly irresponsible advice but it really is comes from this we don’t do diet where it’s just because that information’s come from a reliable source it’s still going to get ignored because it’s to do with diet.

Dr Hariharan Kuhan
I mean, this is it. This is what again, so having had the opportunity to self reflect on my own shortcomings, you know, you know, I’m sorry to say this, but an oncologist and medical oncologist these days purveyor of a protocol, you know, a protocol that’s given to them based on the evidence and all that stuff. But that’s what they execute. And you try and ask them questions around anything else there. Maybe they don’t have the time. They don’t have the time. I remember the hustling and bustling. And it just connects to seeing 40 odd patients. If you know, you know, it’s all round. You can’t really be a good doctor. I remember having that thought because of the pressures. But you think, you know, if you get asked enough questions about something, you read about it. You learn, you educate yourself, you inform yourself. Why does it have to be spoon fed to you as a doctor? Why can you incorporate into that practice what you read yourself? And if you ask questions enough, surely you should want to do so. So that’s, again, one of the failures I see time and time again. You know, this belief as well that somehow standard of care treatment isn’t causing metabolic in, you know, craziness, harmony. The fact that giving someone chemotherapy isn’t causing an array of issues on the inside of the chaos on the inside of the body. We pick this up with our bloods all the time. You know, you know, this is the thing. I mean, you know, and the diet, like you said, I, I, I’m puzzled. I mean, I guess there’s a lack of education, right? So even if you, there are nurses in the past who, you know, when a patient would reflect to me, they tell the nurse, they were, they were fasting on the day of chemotherapy or, you know, the day of the night before. And the nurses were in horror with the horror. They were like, well, standing by the patient, ready to catch them in case they fell backwards. You know, and maybe I would have thought that as well in the past. And then, you know, but I’ve again had the opportunity to learn by observing and asking and talking to people. But you slowly, when you look at the data, you know, and then again, part of my thing is always education. So when I talk to people, I, I try and consolidate some of the themes that they might have come across in their own reading before they met me. So I’ll say, look, we’ve heard of the buzzwords ketogenic diet, intermittent fasting, fast mimicking diets, you know, low glycemic index, index Mediterranean diets, the common denominator, low in carbs. And then I just try and explain that one size doesn’t fit all. You know, there are nuances to it all. And it depends on you as an individual and look into these themes and read about them and find out what fits you and what’s sustainable. If you can go low GI, there’s a lot of data, a lot of evidence base that supports its relevance. You know, you know, ketogenic, we’re in the infancy there. I mean, a lot of interest in brain cancer and prostate cancer and, you know, maybe not necessarily in all cancers and needs to be done under supervision and there’s different sort of interpretations of it.

Dr Hariharan Kuhan
But again, watch the space, learn yourself, read a bit more, but you find out, you know, you know, I always try and again express to people, you can’t fire on all cylinders at 100%. You can’t run a marathon, have absolutely no carbs, you know, you know, be absolutely disciplined in every aspect of your life, take a lot of metformin, take a lot of berberin and expect to be all right. You know, it’s about a balancing and juggling act for the individual, which again is why you need them on board and them to understand and again, just have some sort of tact to where you introduce these things.

Robin Daly
Okay so what you’re indicating is that COC is moving in a slightly new direction now. In the past you were going for these kind of headline figures of like we can get somebody with a nasty brain tumour to live twice as long. That’s a big headline. It’s obviously well worth having at one but you’re actually aiming slightly differently. Now I don’t know are you doing both? You’re keeping doing both. We’re doing both. Yeah to be fair.

Dr Hariharan Kuhan
So with us, we truly believe like, I mean, we’ve, you know, we have to always interrogate our data and find evidence of positive signals. And, you know, we can’t always release all that data just because the way we collect the data, we have to, there are certain constraints in doing so. But one of our ambitions is to kind of present more case theories in case reports and things. But like, actually, the problem there is that, like, I can do any number of case reports in case theories, but it won’t turn the mindset of a conventional oncologist. And so what we got tired of doing was basically going down a dark tunnel to a hitting a wall whereby, yes, we got some interesting data and the patients might be interested in it, which obviously is just probably as important, but it wouldn’t move us forward. What we wanted to do is move forward, collaborate with academic institutions, get more funding for larger number studies, do randomised control trials and really break the back of this. So this becomes part of the public sector, right? And not just the money thing in the private sector. We don’t want to be just hidden in the private sector. Patients shouldn’t have to pay for this. Patients should be able to get in a metabolic protocol via their GP, etc. You know, that’s the way it should be, right? And that’s the way we’re raising that culture of the NHS. So, but to get to there, to get there, you need to convince these characters and these very strong world academically numbers based people. And so this ambition was to have these metrics to be able to track data better, to be able to say, here’s point A in time, we can see the metabolic issues. Let’s rectify this with repurpose medicine, supplements, nutritional talk, exercise talk, you know, stress factors talk, and let’s recheck them in point B in time, three months or six months down the line. Can we then prove that we’ve enacted these changes? Can we synchronise those improvements with how you’re doing in general in the cancer setting? And we can validate things and kind of again, kind of link over to the publications that do exist. So there are publications over the last couple of years that have validated the importance of insulin resistance and the outcomes in cancer patients, or metabolic syndrome and breast cancer and brain cancer, more and more of this is just being published and published to publish and the relevance of metabolic health. And so we can tailor and tag our data to that proof, you know, published data or read, yeah, and get this awareness more like quicker, get out there, get out there a lot quicker. And next thing you know, we can and that’s why we’re actually in talks at the moment, with various London institutions, one is Bart’s Health Trust, which is the biggest health trust in the country, with review to with a view to trying to start a randomised controlled trial or get some feedback as to how to move forward with some studies in this space.

Dr Hariharan Kuhan
But that’s that’s it. But it’s taken a few years to get here, Robin. I mean, yeah, published, you know, one of our esteemed colleague, doctors, Dr. Samir Agarwal presented at a neuro oncology conference in Liverpool in the summer. And there was an overwhelming, you know, positive response to his to his talk. And actually, you know, they asked for a show of hands of who would like to be involved with the trial and study. And there was a large number of hands up, but I’m trying to follow up that those leads, those large number of hands dwindled down, you know, down to one or two. So it’s hard, it’s been an uphill battle. But this is the only way we can do this. And that’s why you know, my focus initially was maintaining a good standard of care, good reputation for our clinic. And, and we pride ourselves in doing that. You’ve got a fantastic team. And so, you know, based on the back of that, we just now need to evolve to the next step where we can get our data out. And this is the way forward with this new program, the CSC plus program.

Robin Daly
So as you’re saying what you’re doing is you’re kind of riding on the back of research that’s already been done that says that if you change this particular biometric that the cancer patient and does better on treatment so their outcomes are better. So therefore you’re saying okay we can change this biometric so therefore we must be improving their outcomes. Absolutely. Yeah very interesting. So and the advantage of this is that you can actually get hold of this data quite quickly compared to their eventual outcome, their lifespan. Exactly.

Dr Hariharan Kuhan
Exactly that, Robin. And that’s the thing. We need to get the data out there within the space of a year to two years, get some preliminary data, work off the back of that, have more conversations. You know, once we have the academic verification validation, it just empowers us to be able to move on to getting bigger collaborations going. And that’s kind of really one of my big drives for the clinic, is really to just get out there more and get these relationships up and running and have these conversations with mainstream oncology. You know, and obviously anyone else, anyone else along the way that wants to have this conversation, the more the merrier, which is why I really do look forward to collaborating with yourself, Robin, and, you know, talking with some of your other esteemed guests in G course to get these motions forward.

Robin Daly
Great stuff. So a little question come comment. You know, you started off with your program of repurposed drugs and now we’re bringing a bit of testing, a bit of lifestyle advice, some fasting, exercise, supplements. You’re beginning to look very like an integrative clinic. Do you think you’re heading in that direction?

Dr Hariharan Kuhan
I’d say that’s not a bad thing, you know, for me, like, you know, whatever the labels because I’m just used to labels, you know, what I always used to tell patients, like, you know, I see how overwhelming it is, right? You know, you move away from conventional sense and, you know, the naturopaths and the homeopaths and the Gerson practitioners and the intuitive doctors and the functional doctors and the herbalists and you know, it’s like, as an observer again, a naive observer, right? And they’re all fantastic. And they all have been a strengths and things. And you know, I’ve learned a lot from just reading around the different things. It’s just, yeah, they’re all labels though, right? And I think there’s a lot of overlap. I think we all agree with similar things. And so for us, I think we’ve just, you know, it just proves that we wanted to evolve. We wanted to change with the times we didn’t want to, you know, stay stuck in the past. And we, you know, we had to learn from mistakes, to be honest with you, with the data collection process. So we want to evolve. We want to get data there. We want to do something more meaningful. We have to be embraced of all of the facts that these are things you cannot ignore. And we work in the space, as we said at the very start, you know, we work walking the line. So we’re in the space, whether we want to or not, you know, it doesn’t matter. We’re in the space. So we have to kind of move with the times. We have to do something that’s again, beneficial. And it all overlaps when you realize there’s so much overlapping. It’s not in our business to say, look, let’s just focus on prescribing for medicines and not give it to you. It’s about it. Let’s, you know, we can’t turn a blind eye to anything else that’s important. It’s all part of the same package. And, and to be honest with you, with every single initial consultation I’ve had with every individual, the questions are very similar, right? So should I be eating differently, doctor? You know, we should, can I exercise doctor? You know, should I be seeking some input from the supplement doctor, the integrative doctor? And so these are questions that you have to help people. You have to direct them when if I can do that in some meaningful way, that’s still in line with the ethos of the clinic. And, you know, bearing in mind, we want, we want to be a data-driven clinic. Now, I’ll focus more on that. Then who am I to say no, you know, who am I to, to, to, to, to, to kind of close the wall or, or, you know, or shut off that conversation? I think that’s what I’m really grateful for, for this evolutionary aspect that I can now openly talk and draw upon the experience I’ve gained over time. You know, I think in fact, we kind of, I don’t know whether this term exists, but we consider ourselves metabolic doctors now, because we spend so much time delving into the research and discussing this package and the science behind it, the evidence behind it.

Dr Hariharan Kuhan
And, you know, we’ve had some fantastic collaborators as well. We’re putting together this package over the, over the last year or so, but we really feel that this is a niche that we can, we can focus on and, and pioneer.

Robin Daly
Well you have and I think it’s marvellous that you’re coming in the other direction so to speak. It’s interesting to see that many integrative doctors now of course embrace repurposed drugs. So they’re moving in the opposite direction towards you as well.

Dr Hariharan Kuhan
know, fascinating, isn’t it, Robin? Like I, because you get you’re weary of there’s always these kinds of whispers behind the scenes or that person said this about this and that person doesn’t like this or, you know, when you hear these little stories and things, and I get it, I think a lot of it is just a lack of communication, you know, and I think that’s one of the things I think, you know, maybe that’s one of our failures as a clinic, which we’re trying to rectify by having a bit more face time and just, you know, doctors talking and hearing us talk and, and double was was you obviously met him lovely, lovely guy, you know, yeah, still full on boy, he’s in academia, he works at King’s College, he’s into the neuro neuroscience aspect of academia, you know, which is amazing. And Dr. Padman is my other colleague, who’s a full time, you know, another medical lead here. Again, just just the highest caliber doctors, but I think he’s not had much exposure. And so with us, I think it’s about having these kind of collaborative discussions with pioneers or one of the pioneers in the space, you know, I’d love to, you know, that’s the only way forward to kind of just dismiss, dismiss understanding the fact that we are happy to be flexible, we will happily say we’re wrong, we will happily, you know, debate things openly with people and learn and evolve. And I think that’s all we can ever anyone should strive to be able to do. You know, because nothing is clearly, clearly defined here. And I always try and say that the art of weaving this all together hasn’t been defined. And this is the space that we’re working in. But if we can do that together and have conversations as you have helped, you know, you know, propagate, then surely that’ll lead to something great for the future.

Robin Daly
I think so. I mean the great thing about integrative medicine for me is that it basically asks the same question as any sensible patient asks. Is this likely to help me? Is it a repurposed drug or is it a supplement or whatever? Is it going to help me? I want to live. I want to have a good life and so that’s the question. That’s where the practitioner should be standing alongside them in the same place.

Dr Hariharan Kuhan
And you know what, early on, again, in my neon naivety, you know, when I was first often asked about Fenbendazole, right? Sorry to bring this up. Early on, again, as a conventional doctor, it kind of, you know, confused me. And I remember talking very early on, I think this has been my first few months at COC, a patient put to me, doctor, like, I’m facing my own mortality here, right? Like, I remember very vividly a single dad, you know, desperate situation, reams of supplements, Fenbendazole included, I’m willing to take an element of a risk, if it’s going to help me live, like, you know, and that stayed with me, right? You know, and there are certain situations of conversation you have with people along your career, you know, that just, you know, imprint things into you. And I’ve never been abrasive since that point. Like, I’ve always been humble and always listened to people. And since that point, especially, assuming, you know, that that whole, that whole, the whole, the whole, the whole of knowing everything is gone, like, you know, one of the things I tell my patients, I learned something every day, there’s something new to learn and pick up from people. And you can’t expect to know absolutely everything, you can’t know exactly why cancer is developed, we’ll get there one day, but there are so many influential factors. You know, we can maybe create a story and build a story and whatnot, and in our own minds, but we don’t have that power yet to fully know. So I think with that in mind, you kind of think, okay, look, if I can support a patient, provide them with a safe space in the forum to talk openly with me, respect what they’re coming from, push back if I need to, you know, but they’ll always know and have that importance of understanding of where I’m coming from, which is their benefit, then that’s as much as I should do as the minimum as a doctor. Now, I don’t feel doctors are able to do that to that extent, unfortunately, in the public sector, because of times constraints, I wish I would like to believe they’d want to, they must do those at work in hospital medicine are admirable, you know, what they achieve and the hardships they go through to maintain that that level of professionalism and career and the social hierarchy that exists in that kind of space. Amazing. And I’m in awe of that. I fully respect those guys. But I just think that the time constraints really are against you certainly, you know, to be the best you possibly can in that space.

Robin Daly
Okay we’re going to have to end it there Hari. It’s been very inspiring to talk to you. I mean it’s great to hear that care oncology is continuing to develop. I love it. I have a great admiration for new initiatives in cancer care like this. Bring more options to the table for people with cancer and you know I just applaud you and your team for being up for the many challenges there are when you want to break new ground.

Dr Hariharan Kuhan
Thank you. Thanks, Robin. Like I said, like it’s, it’s really important that we do more, you know, such talks like this, and I really appreciate the efforts that you put into this, helping patients, you know, and I said it before, I think I’ve said it offline, you’re the work with the charity that you do, the websites, the information that people can gather, and the fantastic guests that you’ve had on in the past as well have been a really good a source of inspiration for me, but let alone, you know, thousands and thousands, if not more, of patients. So I really applaud the work that you’ve done, and thank you very much for your time and for having me on. Thanks.

Robin Daly
Thank you, Hari. Dr. Kuhan’s attitude towards his patients is totally exemplary and I would say exactly what anyone facing a cancer diagnosis would hope for, I certainly would. It’s fascinating to see how the ground of integration is being built as those outside of the NHS move to connect with those moving out of the NHS mindset across the chasm that separated the two for far, far too long. Next week, the show is going to be the first of a few that focus in on a very important development in integrative cancer science. Mark Linton has spent the last eight years deeply reviewing the scientific literature, looking for clues as to the origin and mechanisms of cancer and his efforts have been rewarded such that he is now able to give a coherent picture of the inception and all the key behaviours of cancer. While his findings are still firmly in the realms of theory, nonetheless, there is no other current theory that can give this degree of insight into the workings of cancer so its potential is very significant. On the 12th of February, we held a professional event to evaluate Mark’s ideas in front of a panel of 10 cancer experts as scientists, clinicians and patient experts and an invited audience of cancer experts. The response was undoubtedly mixed but overall could be described as cautiously positive with many highly qualified attendees expressing great enthusiasm and interest. So we’re right at the beginning of a journey but there are good reasons to believe that it could take us in a very good direction as regards the treatment and prevention of cancer. So make sure you don’t miss this first important interview with Mark Lintern here on the Yes to Life show.