AMERICAN NATUROPATHIC RESEARCH INSTITUTE
NATUROPATHIC ONCOLOGY RESEARCH INSTITUTE
1250 E. Baseline Rd., Suite 205
Tempe, AZ 85283
JOINT MEETING OF THE
AMERICAN NATUROPATHIC RESEARCH INSTITUTE (ANRI)
NATUROPATHIC ONCOLOGY RESEARCH INSTITUTE (NORI)
INVESTIGATIONAL REVIEW BOARD (IRB)
May 18, 2012
MINUTES AND MEETING NOTES
In accordance with the requirements of the United States Code of Federal Regulations, Title 45, Part 46, the tenth regular quarterly meeting, of the American Naturopathic Research Institute (ANRI) and the Naturopathic Oncology Research Institute (NORI) and the Institutional Review Board(IRB) was called to order at 12:40 p.m., May 18, 2012 at 1250 E. Baseline Rd., Suite 205, meeting in Suite 203, Tempe, AZ 85283.
The following members were in attendance (alphabetically by last name):
Colleen Huber, NMD
Kenneth Lashutka, NMD
Eric Lopez, NMD
Kenneth Proefrock, NMD
Paul Stallone, NMD
Nanao Takaki, NMD
Others who have attended previous meetings or wish to attend future ones are cordially invited to join us for future meetings.
THE PURPOSE OF OUR ORGANIZATIONS AND WHY WE MEET
Dr. Proefrock, President of ANRI / NORI, and then Dr. Huber, Secretary of ANRI / NORI reminded us of why we came together more than two years ago this month to form our organizations: Patient freedom of choice in healthcare is a fundamental, inalienable right that must be upheld. Going hand in hand with this is the need for naturopathic physicians to maintain and expand our scope of practice, in order to be able to treat our patients most effectively.
TERM OF PRESIDENT
Dr. Huber read the Agenda for today’s meeting, which included a decision about the term of the President and the proposal that Dr. Proefrock’s term of office be a four-year term, which is about halfway through at this time. The question of re-election for consecutive terms was not addressed. Dr. Proefrock accepted the four-year period. There were no objections made, and it was unanimously agreed that Dr. Proefrock would continue on as President.
STARTING AND AWARDING OF FELLOWSHIPS
[To summarize the discussion that led to this topic last time, the following is reprinted from the February 2012 Minutes. The first part of the following was from the February 2012 meeting, which raised the idea of the need for fellowships in our organization.]
Dr. Proefrock said that more “legitimate” appearing doctors are attractive to ND students and new NDs for mentoring and rotations and emulation. There is a phenomenon of the little brother seeing what the big brother is doing, as it were, and wanting the same for himself. When one type of naturopath seems to be more employable, more tied in to the massive money of the conventional medical system, there is a desire to get on board with that, and to share in the perceived bonanza.
Dr. Tamburri clarified that students who only see FABNO-type doctors are going to believe that they have to buy their way into a club in order to treat cancer.
Yet, said Dr. Proefrock, FABNO is actually on shaky legal ground, because they don’t believe that IRBs are necessary.
Dr. Tamburri asked the question: Do we need a NORI fellowship?
Dr. Huber enthusiastically responded yes, because although legitimacy is just a veneer that does not reflect any authenticity or lack thereof to the doctor underneath the title, it does have the impact on the public and the profession of a statement of competence and dedication to the field in which certified.
[Today’s discussion on the topic of Fellowships:]
The Board revisited a topic that was raised last time, which was the awarding of fellowships to ANRI / NORI members, based less on past research done by members and more on a presentation of present and proposed research projects, for possible approval and encouragement by the whole Board.
Dr. Proefrock said that the awarding of fellowships is often done by an organization such as AANP (American Association of Naturopathic Physicians), on the basis of certain criteria. These criteria could be clinical experience, examination, ongoing continuing education, etc.
Dr. Huber said that it seemed that an organization looking to establish such credentialing process would need to be self-affirming before it could seek affirmation from the AANP. This would be necessary in order to have something concrete to propose to AANP. At least the process toward such a designation of fellowship would have to be defined by our organization, before we could apply for recognition of the same by the AANP.
Dr. Lashutka said that criteria for determining how a fellowship is awarded could not be narrowly defined in our organization, precisely because we support breadth of practice, and because we do not exist in order to limit or veto treatment options of our members but rather to support the judicious use of any or all valid treatments.
Dr. Proefrock said that a motivation of ABNO was to foster an environment of equality among its members, and that designation was to reinforce that equality among its fellows. He suggested that we obtain a copy of a position paper by other organizations to see how they proceeded. Dr. Proefrock volunteered to look for such a paper.
Dr. Lashutka said that we should determine what a fellowship would involve, given the need to avoid narrowing our medical goals to rigid guidelines. Therefore, an exam would be inappropriate, unless perhaps it were all essay questions.
Dr. Proefrock suggested that case studies would work well for that, a certain number of cases from each doctor.
Dr. Stallone said that this approach has precedent and would work.
Dr. Proefrock said that each doctor should present 5 case studies. We look at those 5 cases, and we ask questions, such as what is happening with the patient now, and questions based on seeking further clarification of what happened during treatment.
Dr. Lashutka said that during each meeting a certain number of cases could be presented, perhaps one from each doctor each time, until each doctor arrives at 5 cases presented.
Dr. Huber asked if there would be any continuing medical education requirements for awarding fellowships.
Dr. Proefrock responded that it would be too hard to find an oncology conference with truly naturopathic presenters, although there would be something to gain from other cancer conferences including allopathic.
Dr. Huber agreed that such conferences are too seldom and generally too distant to expect the membership to all be able to attend. Perhaps the continuing education requirement would be able to consist of individual study of the medical literature.
It was generally agreed that case studies could comprise the primary requirement of a Fellowship.
We agreed that next time we would begin to all bring case studies and begin with these, and that as time goes on more and more of our meetings would be about this.
Dr. Proefrock acknowledged the value of the legitimacy stamp of a fellowship, but also said that our accountability is to the patient base that we serve. That is the crucible that we work in. The way you do things for 10, 15, 20 years is the basis for knowing how to work with patients, not the whims of a distant authority. What is important is the relationship that you cultivate with the patient, the hope that you are able to give them and the love of humanity and compassion that is maybe the greatest source of healing that we have as doctors.
A RECENT CONFERENCE: ADVANCES IN CANCER STRATEGIES
It was generally agreed that because there were no cases ready to be presented today, that we could also use this Grand Rounds time to present information on useful approaches to patient care.
Dr. Huber started this topic with a summary of a conference held in April of this year, “Advances in Cancer Strategies.” Mary Hardy, MD a UCLA oncologist talked about some of the difficulty cancer patients have in dealing with their diagnosis, and our challenge in getting them to a place where they want to live. She noted recent research on the critical role of physical activity, 45 minutes per day on long-term outcomes.
John Boik, PhD, a Stanford University chemist, helped develop a laser assay, which did fast, label-free, 3-dimensional, real-time imaging of a drug on cancer cells. These are multiple tuned lasers focusing a pinpoint spot in a cell.
Dickson Thom uses a protocol from the late Bill Mitchell, ND: Give Juniper to patients on chemotherapy to help them clear tumor breakdown products.
Dwight McKee, MD is an oncologist who summarized oncologists’ view of cancer patients: “We’ll throw chemo at it for a little while. Then go to hospice.”
He said that using anti-angiogenesis strategies while a tumor is present encourages mets. Wait till zero tumor burden. Then use tetra-thio molybdate. à Take ceruloplasmin down to 10 mg/dl +/-2. OK if Hgbà10. Dr. McKee believes there is a huge opportunity for thermal ablation and radio or electrical ablation to replace a lot of surgery.
Jason Williams, MD is a radiologist doing radiofrequency ablation in Alabama.
Dr. Proefrock mentioned that Scott Tropper, MD was doing radio-frequency ablation here in Scottsdale, among others locally as well.
CASE PRESENTATION FROM DR. HUBER
The following case is one that was written up in the last Minutes, but did not make it into discussion either last time or this. Dr. Huber requests that the Board consider this as one of her presented cases, for discussion at the next meeting.
A 55 y.o. woman with stage 4 breast cancer, with a history of lumpectomy, and on and off chemotherapy since 2000 presented to our clinic one month ago. The secondary metastases were to the liver, which had been almost completely replaced by cancer at the start of our treatments. Chemotherapy became less and less tolerable, mostly due to intolerable mouth sores. Fewer, smaller, shorter doses of chemo were given by her oncologist, until there was nothing that she could tolerate anymore. She gave up on chemo and moved to Arizona for our treatments. This woman’s wellbeing improved somewhat during the first two weeks at our clinic. The mouth sores cleared after about a week. She did yoga and power-walking. Then there was a week away out of state, with I believe no medical treatments of any kind, nor major changes in diet. Then on return, the health drastically took a turn for this worse, and the patient died this past Monday. This patient was an engineer who was meticulous about tracking her blood results following chemotherapy and wanted CBC/CMP blood labs once per week, which we did. Blood labs started coming toward normal for all analytes except liver enzymes, which steadily worsened, both back during chemotherapy before arriving to our clinic, and continuing after chemotherapy, until AST and ALT were close to 300 at the last blood lab.
The worst affected lobe of the liver, unfortunately for this patient, was the caudate lobe, which you’ll remember is where you find the hepatic portal vein, hepatic ducts close to juncture with the common bile duct and the hepatic artery. The adjacent quadrate lobe was also in bad shape, and again most of the liver had been replaced by cancer over the course of the previous 12 years.
All through treatment, and for the prior year, the patient had copious oral eructations, with a painful feeling of trapped gas in the abdomen. One carminative after another was tried, natural and conventional, with no effect. A colonic had once made this worse, and the patient was not eager to try colonics or coffee enemas. During her last week and a half, jaundice and ascites became apparent. We feared compromise of the above vessels and ordered a MRI. This is where things became confusing. The portal vein was clear and uncompromised. The bile ducts were not dilated or kinked, that we could see. The caudate lobe was atrophied, and although the liver had been almost entirely replaced by cancer, the radiologist found no uptake of contrast aside from that expected in a normal liver. No mass took up the contrast. The cancer appeared to be inactive. We were of course expecting mass effect on the large vessels into and out of the liver, but neither the patient and I nor the radiologist saw any evidence for that on the MRI images.
Within a couple of days, I recommended going to the emergency room after the jaundice, ascites and green-black stools (after high greens intake) presented all together. The patient wanted to hold out and wait till last Monday to see a GI specialist, despite my recommendations, because she feared too much of a revolving door of doctors in the hospital.
But Monday didn’t come soon enough. On Sunday evening, the patient began to vomit blood, collapsed and was taken to a hospital that has previously shown hostility to patients who have chosen natural treatments, not going to either of the hospitals that I had suggested earlier in the week.
When I got to the hospital on Monday afternoon, the patient was restless, drowsy, with dyspnea, with an O2 sat of 99%, BP = 73/33. A nasogastric tube was removing medium to dark red blood. The nurse told me the patient was losing blood as fast as they were putting it in her, and her hemoglobin had gotten down to 5, which explained the air hunger, but little else to me at that time.
I got on the phone with the GI doctor who had just seen her. He said her platelets were very low, and it was strange but she almost had a DIC-like condition. He could not scope her because there was too much blood to be able to see anything. The patient had told me when I arrived to the hospital that the ascites fluid removed in the paracentesis appeared to be clear, although there was non-stop blood being drained from her stomach by the NG tube.
The GI doctor’s differential included a bleeding ulcer and/or the cancer breaking through to the stomach and an artery. He was surprised when I told him about the lack of contrast uptake on the MRI of a few days prior. Yet, still thinking macroscopically, and still suspecting obstruction in the caudate lobe, I asked him if stents could be placed. He declined as explained below.
Dr. Proefrock and I later suspected that what may have happened was that the liver was so compromised that a person who previously tested normal for G6PD may have lost her ability to make G6PD. This is turn would explain the jaundice and the DIC condition, coming from hemolytic anemia.
G6PD you’ll remember is necessary to test for prior to IV Vitamin C, because it is necessary to dehydrogenate glucose 6-phosphate. This adds a H+ to NADP to produce NADPH. NADPH in turn converts oxidized glutathione (GSSG) to reduced glutathione (GSH). Reduced glutathione in turn can neutralize oxidants such as H2O2, which are hell on cell membranes, particularly the vulnerable RBC (except when protected by catalase, which normal non-neoplastic cells are, because catalase breaks down H2O2 to H2O and O2. Cancer cells are different in part for not having catalase, making them more vulnerable to the H2O2 from Vitamin C. Remember H2O2 is produced in the extracellular fluid from high dose intravenous Vitamin C.) Without G6PD to give all this protection, the RBCs lyse, spilling bilirubin into the bloodstream, showing up as jaundice and producing the fatigue of hemolytic anemia.
The hospital doctor told me that he was not going to do anything for this patient except palliative care. When I tried to persuade him (and even tried to guilt-trip him) to do more, he said that life has to end at some time for everybody, and at most she would have three months, and that my concern made it seem that I was more of a friend to the patient than a doctor. I wish I had said, well, we’ll take the 3 months, because as it turned out, the patient died only a few hours later. The family didn’t even have time to fly in and say goodbye. The blood loss was so severe that the blood pressure fell from 73/33 when I arrived to the hospital, to 29/15, and consciousness was not regained. To be fair to that doctor, not a lot can be hoped for with an uncontrollable bleed and/or DIC. And no amount of stents would have made a difference.
The moral of the story is, and this is what I wish I had figured out in time, and will always regret that I hadn’t:
|When a patient with a very diseased liver gets jaundice, and your therapy includes high-dose Vitamin C, there may or may not be any bile duct compromise. Go ahead and run a new G6PD lab, because it is hypothetically possible (although not yet documented in the medical literature that I can find) to have a normal to deficient seroconversion of your patient’s G6PD, and you may have to discontinue the vitamin C in a hurry.|
On the other hand, what looks like a bleeding ulcer on a patient recently finished with chemotherapy may simply be a bleeding ulcer. And what presents as portal vein obstruction and bile duct obstruction in a person with a very diseased liver may not show up in imaging, and may be what it looks like from signs and symptoms. For the above patient we will never know.
NEXT BOARD MEETING: Friday, August 3, 2012 at noon, at the usual place, the clinic of Drs. Huber, Lashutka and Jemison, in Tempe. Chipotle’s will be served, unless objections surface before then
Please remember to bring your case studies in to present.
Dr. Huber continues to offer for her clinic to provide lunch for the meetings at no cost to the membership, in order to save up the usual $10 dues per quarter per person to pay the $400 fee for the eventual incorporation of the non-profit.
POSSIBLE AGENDA ITEMS FOR MAY 18, 2012 BOARD MEETING
The members present agreed to bring in at least one case each for discussion at the
next meeting. This will comprise almost the entire time of the next meeting.
Anything else? It’s always okay to add to the agenda, even at the last minute, but preferably earlier.
Colleen Huber, NMD
Secretary, ANRI / NORI