Welcome And Why Integrative Oncology

Dr Andrew Greenland 0:00

So welcome to Voices in Health and Wellness. This is the podcast where we speak with clinicians, founders, practitioners, and innovators who are helping redefine what care looks like today. In this episode, I'm joined by Dr. Raymond Chang, an integrative oncology physician and founder of Meridian Medical. Raymond's work sits at a fascinating intersection: conventional oncology, strategic integrative care, and alternative approaches for cancer treatment. Today we'll be exploring how cancer care might evolve when we think less in terms of single linear interventions and more in terms of carefully considered combinations. So with that welcome, I'd love to, Raymond, I'd love to welcome you to the show. Thank you very much for joining me today. Thank you.

Dr Chang’s Path Into Unconventional Care

Dr Andrew Greenland 0:39

So maybe we could start a little bit about your journey. And could you talk us through the journey that led you to the work you're doing today? So from conventional medicine into integrative oncology and then development of Meridian Medical.

Dr Raymond Chang 0:52

Let's start quite a few decades ago, actually. When I was still on the packaging for now and employed by the Slone Cattering Cancer Center here in New York City, I took on an interest in alternative and complimentary medicine. We're talking maybe early mid-90s. And along with Dr. Woodson Merrill here in New York, we started offering CAM, I'm not sure what's even called that back then, but complementary and alternative medicine to medical students at Cornell as an elective. And to our knowledge, and I did that at Cornell in Woody, Dr. Merrill did it over at Columbia. We did it at the same time, jointly, planned the current Columbia invited speakers, etc., to give medical students an exposure. And I believe at the time it was the first time that's offered in medical schools. But then eventually it came to a point that I would like to integrate it in my practice, but it's not doable, of course, at a traditional conventional guest center. And then I had to make a career choice. There was support within the institution of allowing me to do something like that. Dr. Sidney Winor, who was the head of the gastroenterology department at Stone Kettering at the time, his wife had suffered from cancer, and he got interested also. So he there's support within physicians at the center and amongst board members as well. But then I decided to go my own way because I think it would be this would be less pressures from the top, what you can do, what you cannot do. So I left Sloan Kettering, but I remained in New York City. And upon leaving, I took upon the making sure that I said, I how do you how does one define alternative at that point? I said basically I will not offer patients anything that's offered at the institution that I'm from. So basically, I won't do any of that, so there's no competition. So I will only offer what's not offered. So actually, my definition of this complementary alternative, I would call it unconventional, conventional being standard of practice. So to distinguish that, I called it unconventional medicine. So there's subtle differences between complementary and alternative, which is either law or unconventional. So conventions defined by regulations and not defined by whether it's scientifically valid or not valid. So I think it's scientifically valid treatment, but yet that's not conventional in the sense it's accepted, licensed by the government, approved by the FDA, and incorporated into the standard of care protocols. So that's unconventional. So subtle differences. So that's what I decided to do.

Dr Andrew Greenland 4:18

From that, I'm trying to understand. Was there like a particular patient experience or a clinical frustration or a gap in the system that made you feel this is where you wanted to focus

The Wake-Up Call At Sloan Kettering

Dr Andrew Greenland 4:27

on?

Dr Raymond Chang 4:27

Yes, there was an incident, actually, that was a little bit of a wake-up call. A patient, not my patient, but I came across a patient who himself was researcher at Sloan Camp or at the Rockefeller University, which is affiliated, which is right across the street. I don't recall now. And if I recall correctly, he actually was awarded the Nobel Prize. So he was quite a well-known, established scientific researcher, and he himself had cancer. And we were just talking, and he asked me about Chinese medicine. And I said, Why don't you look into this? I don't even remember the particular herb, etc. And I wrote the name of the Chinese medicine on my prescription pad. Just a script. Next thing I know, a few days later, I got a call from Dr. Paul Marx, who was the president of Slong Gettering. He asked me to go to his office and asked me, Dr. Channing, I heard that you are right, you are prescribing Chinese herbs to our cancer patients. I said, no, I was having an intellect academic intellectual discussion with one of our researchers who happens also to be a cancer patient here, but he's not my patient. But just out of convenience, the piece of paper that was handy was my prescription pad, and I wrote down the name of an herb for him to look into. He apparently took that and went over to Dr. Marx and asked him, Do you know anything about this? And Dr. Marx at the time thought I was prescribing Chinese medicine. So that bothered me a little bit. And I that maybe if you ask for one incident, that's one incident. There are other incidents that made me rethink is it really that serious to even mention Chinese herbs or kids, which to a traditional Chinese medicine practitioner would be just a very, very natural thing. There's nothing wrong with it. Plus, there's research and etc. So that really bothered me that the system was so rigid. So that's one of

Building Meridian Medical And What It Offers

Dr Raymond Chang 6:46

the things.

Dr Andrew Greenland 6:46

So tell us a bit about Meridian Medical. What's the sort of setup that you have there, and what are you doing to help the clients that you serve there?

Dr Raymond Chang 6:54

It's a boutique practice, and it's been like that since it's just me. And at the time there were other doctors with me. We offer consultations for mainly cancer. But my my interest spans into other kinds of diseases, Alzheimer's, etc. And at a point in time in fertility. And to me, I'm a Buddhist. So to me, actually, I got involved with fertility because we deal with cancer, and then we see a lot of people going, passing on, and to keep a balance, it's actually nice to help people make new lives come in or to bring new lives into this world. And I at the time, again, in the spirit of alternative treatments, traditional medicine, etc., I came up with the idea of using acupuncture as a treatment for infertility, especially in conjunction with IVF, making test your babies. And we I did that for a while. But this idea, and again, I'm one of the first, if not the first, to publish this along with Dr. Pak Chow and the head of the IVF program, Zeph Rosenwax, over at Cornell. They have an excellent program while we're now for doing IVF. And we proposed the possibility of enhancing IVF success rates with adjunct acupuncture. But now everybody's doing it. I'm no longer that active in doing this. So along the way over the past several decades, we've done these different things. Our group also hosts a Tibetan, traditional Tibetan doctor, the Pun Sok, who actually that came about because I co-chaired the first International Congress on Tibetan Med that was held in Washington, D.C. and was inaugurated by His Holiness, the Dalai Lama. And His Holiness at the time pulled me aside and asked me, Dr. Chen, you have an office. Is it possible that we send one of our Tibetan doctors to be like a resident physician in your office to help take care of some of the refugees, the Tibetan refugees, because they are not keen to seek Western medicine? So it would be nice if they can see their own doctors or their own kind of doctors. So for again, almost 30 years, we've hosted Dr. Punksok in our office still, and he sees people who are interested in this kind of thing, Tibetan medicine, which can be the local Tibetan community or other Westerners who believe in that. So that's truly all that.

Dr Andrew Greenland 9:55

So we do an array of things, as you can see. So you're the founder of Meridian Clinic. So what's your role as founder in the day-to-day? And what does your what does a typical day look like for you as a clinician?

Dr Raymond Chang 10:05

It's mainly it's consultations. And again, in the past 10 years, everybody has branched into the into remote virtual, especially with COVID. So we see patients from C patients online from around the world, usually from for second opinion types. What else can I do? Can you help us with our diet or with supplements? Are there any other treatments anywhere else in the world? So we look for treatments basically from anywhere. I remember engaging in helping patients look into getting thalidoline from Brazil before it was reapproved back in the US because it was banned for a long time. And for as an example, then we would help people look for it in South in Brazil, it will it remain available on the market over the counter as a sleeping pill. But again, so things evolve this way. So I keep myself to doing what's unconventional. Whatever's offered mainstream, I don't touch it. I advise on it, should I do this? We don't tell people you shouldn't do chemo, you shouldn't do radiation, that sort of thing, or you don't do surgery. So we advise on it, and where appropriate, we would still tell patients, yes, that's the thing to do. But in case there's something else that they cannot access, they cannot, there's something that's not available conventionally through the institutions, we will try to assist them in pointing the way where to go, where to get what, etc. etc. So as soon as it was subsequently was approved, and now it's morphed into Rev Limit and it's standard of care. So for my low minds, that so we no longer engage in that, the little minds no longer. So that's an example. So there are newer things that like certain viruses, oncolytic viruses that's not available in the US, that we would refer patients to out of the country to access. Basically, so we watch out for what's new around the world. Sometimes things are new to the extent that it's still owned, held by the drug company. It's investigational, so it's not yet generally available. So we also try to help the patients to see if we can access something, say on a compassionate basis, before it hits approval, before it's approved. But maybe they can we help them reach out to the company, etc. etc. Something is very promising. So basically, we try to look into newer things or different things that's not available. I think there are lots of things like that. That I think that the standard of care is quite limited if you look at it from a more universal, worldwide international kind of perspective.

Linear Care Versus Cocktail Strategies

Dr Andrew Greenland 13:27

So you refer to unconventional quite a lot in your description of your approach, but you also have a philosophy around linear versus cocktail. Can you pursue your your what your classification means in that context?

Dr Raymond Chang 13:40

Again, I think this is very interesting. I think it naturally comes to mind, to an especially an Asian mind, that certain things, it's very interesting. It would go back to philosophical roots. I think the Greco Roman mind tends towards linearity. And this is again very broad assumptions. And I usually point it out using the dinner table as an example, that very often in the West, things are served one after another, so you know pre-dinner cocktail and appetized first plate, second plate on training dessert, etc. It's a linear. Whereas, of course, if you go to a Chinese meal or uh especially like Dimsa, it's many things on the table at the same time, and people just grab and get what appeals to that personal personal like music. So it's not one thing after another. So that that way of thinking, I think if you have choices and it the it's easier to tailor treatments to the individual, just like if you have choices in food, it can be better tailored to the taste of the diner, you can pick whatever they like, etc. And also, I think just simply mathematically, or not even mathematics, but just simple arithmetic. I always use the example of gambling that, as in uh say a LED game or any other game, where you only have a certain chance of win per play, per turn of the wheel, that wouldn't it give you a better chance of winning that game if you were able to make more than one bet at a time. So the linear approach, which is very much the Western standard of care, is you have this diagnosis, then you get this treatment up front, let's say ovarian cancer, it's carbotaxo as the treatment. It's either so there's neo-adjuvant treatment before surgery, adjuvant after surgery, etc. So things progress linear fashion and usually one regimen at a time. If you fail carbotaxo, you recur, then subsequently a different chemo regimen. If you fail that, then a third one, but diminishing returns, because of course, ethically, the most effective treatment has been offered up front. If that fails your offer, then unfortunately, it will be a lesser regimen and lesser regimen. So basically, not only are you allowed to make one bet at a time, but as time goes on, if you keep losing, your bets become smaller and smaller. So that looks to me like almost guaranteed failure. That path. And there are many practical reasons. I think the system works like this, is that to allow people to make more than a bet at a time, say they want to place multiple bets at a time, will get better outcome. But of course, it's at least in not only the US, I think even in socialized medicine, where the other side, the payers, such as your National Health Service, will have to consider cost. You cannot have everybody, you cannot let everybody have as many chips as they want and place as many bets as they want. Because that will cost you. The outcome is the outcome should be better. Again, you place three bets on three numbers on the roulette table, you should have almost three times the chance of winning. But it will cost triple the number of chips. So unbeknownst to patients, except they just think, oh, that's the right thing to do, I should do. The doctor told me I should proceed on with this and try this first. If this doesn't work, then we go to that. But that's partly the system set up that way, partly because payers don't want to have you do three things at the same time. And they would often say, let and they will let you do things and they will let you do the cheaper things first. And the argument in the US, for example, you have to get pre-approvals for treatments from the insurance before you can do it all. Otherwise, they will not reimburse. One question that always comes up is haven't they have they tried and failed the prior, lesser treatment already? If you cannot say, so let's say three treatments, you know ABC is superior, but if they haven't tried the cheaper, easier, older treatments first, sometimes the insurance, the payer, would reject your requests for using C because it costs much more. It's newer, it costs much more. They haven't failed A or B. Why don't you try that first? So the patients might think that we're offering as physicians the very best treatment that's available for them, but not exactly. It's the very best treatment allowed by their coverage, allowed by their coverage that we are offering. So that that kind of approach, the system that we're in, also limits the ability to deploy this multi-pronged and multimodal kind of approach, unless it's very well established by science. So, good example is HIV. It was very clear that a cocktail of three anti-HIV drugs is much better than just ACT, for example, in very early days. And Dr. David Ho came up with this cocktail idea. He's from Taiwan originally. So again, I think Asians tend to think it more in cocktail terms, multimodal terms. So, but that is so obvious that triple therapy, cocktail therapy is so much better in terms of outcome for HIV that yes, insurances will have to cover it. So that's kind of the background. And then, of course, we are taught as physicians constantly that polypharmacy is a bad word, that drug-drug interaction can be nasty. So we're liability conscious and so conservative that we're very reluctant to put into place cocktails. We don't know what the interactions are, we don't know what the side effects might add up to be. And that's not the standard approach. So let's stick with one thing at a time, it's easier, simpler, cleaner, which is true. But again, you could again, this Asian mentality, you may be surprised, people may be surprised to learn there is almost no traditional Chinese remedy, herbal remedy, or even acupuncture that deploys only one herb at a time. There is one classical formula called Tu Sintang, it is Jinseng only. And the use of the application is very limited. Everything else is a combination of multiple herbs. And each herb, of course, has multiple ingredients. So it's layers of complexity, it's cocktail upon cocktails. Acupuncture, there are there are an occasional perky acupuncturist who claim that I only put I only need a one single point, but that's not the same. Classical acupuncture will always involve more than one point. You don't just need a one acupuncture point, that's ridiculous. So this idea of a cocktail approach, the multi. Multi-feted approach is natural to an Eastern medicine type of approach, but very unnatural. In the Western frame of mind, we're always looking for the one pure compound. Penicillin kills strep. We use penicillin. Penicillin doesn't work, still have a sore throat. Three days later, you come back. Okay, then I use augmentin, I use SIPO, etc. But you try one thing, see if it works, doesn't work, come back, then we advance to the next level. It's not, we don't solve three antibiotics. At least that's the classical. It's always this linear. Single pure compound linear, this is very western.

Repurposed Drugs And The Trial Problem

Dr Andrew Greenland 22:46

You mentioned repurposed drugs earlier. I was curious to know how do drugs end up getting rediscovered for something completely different from their original intention and find themselves into the oncology space.

Dr Raymond Chang 22:57

It's not a new thing, and we all know that. Many drugs, and then these older drugs, came from nature. Aspirin from willow bark has multiple properties. It can be used as an antipyretic, it can be used for pain, etc. It can even be applied topically on words, right? So that's in a way repurposing. So if aspirin was only indicated for fevers, and then you start using it for other things, and then it truly repurposing, we use it as an antiplate to prevent heart attacks and strokes. That's repurposing. So it shouldn't be such a novel idea. But for oncology, it is somewhat novel because we are so used to starting from mustard, the derivative from mustard gases, the early chemotherapies. We're so used to single compounds. We look at this, does this to the cancer cell in the lab, the mechanism is like this, it's psychotoxic, etc. etc. And so this whole approach then makes it, then we we were not looking at other things. At the time, the word was not re at least. I publicly put this in a blog out 2008, 2008, 2009, the idea of uh what's now called repurposing. But back then we favored the term, I favored the term, off-label use. It's not something that the FDA has allowed to be put on the label as an indication. So it's off-label use. So it's a legal definition of what is repurposing. That legally you shouldn't or you cannot use it for that purpose. You shouldn't prescribe it for that purpose. So it's off-label. But off-label has always been tolerated. Insurance companies don't tolerate, they're not going to cover it if it's off-label. But as a matter of practice, doctors are free to use a drug as they see fit to a certain extent. That is, there's a wider, there's more leeway there. So that's called off-label drugs. So all these things, the metformin, the statins, etc., the research was known then that they all had properties that make them fit for anti-cancer drug discovery. But the problem with most of these off-label things is that they are cheap and they have no patent. And very few, certainly, institutions and certainly drug companies are not going to research it and to do a trial using it because they don't own it anymore. It's generic. So it's very hard to get studies going on these old, old and cheap generic medicines, which is the case now that the very popular what I call TikTok medicines that I permit in Benedict's all over the place. Everybody asked about it. But there are no good trials. Because who's going to pay for it? And who makes it? It's not Pfizer, Johnson, Eli Lilly, they don't make these drugs. So there's no big funding behind doing good formal clinical trials. So in a way, they will forever remain off label because you don't have the trials, and no who is going to submit it for an approval through the FDA? Nobody, because my company, if I make a generic version, am I going to apply to the FDA to say study Mebendazole, and then I get an approval, and then what? Then everybody else can buy Mebendazole from suppliers all over the world. So why should I put in the money to do the research? So that's the problem with these operations.

Dr Andrew Greenland 26:55

Thank you. So what are patients typically looking for when they come to a practice like Meridian Medical?

Dr Raymond Chang 27:00

I would say, and it's somewhat unfortunate, that people usually count late and they're referred to as late because usually it's when they're out of options. Like nothing works. Things are not working. I think when patients are first diagnosed, of course they go to the regular doctors, they panic mode. I have just been diagnosed with brain cancer, breast cancer. It's only when things are not working out that I think they start looking for feminists. So that's the majority. And then I think there are some who are just looking at prevention. They have a high-risk situation with a gene, for example, women with BRCA, they're looking at prevention. So standard or conventional medicine doesn't really have any preventative protocols. If you have a BRCA gene, you're at high risk, or they will talk to you about considering prophylactic mastectomy or prophylactic orphorectomy, but there's no real discussion to either preventative methods, either off labels, supplements, vitamins, lifestyle, etc. So that that's not really incorporated. So those so for things that they cannot find a conventional solution, they might seek us out to look at alternatives.

Who Seeks Meridian And Prevention Gaps

Dr Andrew Greenland 28:23

I want to switch gears a little bit and talk a little bit about the kind of the business side of running a practice. Oh, yeah, sure. So from a business and operational perspective, what have been perhaps some of the biggest challenges in building and running Meridian Medical from your perspective as a founder?

Dr Raymond Chang 28:35

I try to stay clear of that. It's not that much of a challenge. It's a challenge. But we're very small. As I say, we're boutique, because of course the conventional world dominates. There are very few of us, actually. And the whole trend, at least in the US, is private practices are 5%, I would say. Most even small groups have been bought up by hospitals merging to larger groups. And the reason is in the growth of the past 30 years, the tremendous growth in the complexity of the administrative and deal with insurance. I think for every one doctor, there's at least four administrative assistants just to deal with the insurance part and to deal with payments, insurance. And that's the complaint I hear from my fellow doctor colleagues who are still in practice. Their biggest complaint is, you know, denials, taking forever to get reimbursed, especially for cancer, where the drugs are expensive, so they have to purchase these very expensive drugs, administer it to the patient, and wait six months to get reimbursed. So there's cash flow issues like that. So, in a way, for my practice, since we're out of the box, as a matter of principle, we don't participate in healthcare insurance. I don't take insurance payments. The patient can go and claim their insurance themselves. We give them a bill, etc. So they are free to claim it from insurance, but we don't deal with insurance. So we don't have insurance, we don't deal with insurance directly, at least in the US, that system. It's very so we're very different that way. So patients will pay us directly, and the rest will be between them and their insurance company. Because again, we do unconventional, so all other things are not going to be covered. So of course, we we if we participate in insurance, we would be under the thumb of the insurance companies of what you can do, what you can't do, because this we won't pay for that, we won't pay for so they will only pay for conventional treatment. So that will defeat the purpose of my practice. So you know so that restricts the number of people who come to us because sometimes they call, and first thing they hear, oh, you don't take insurance. But again, those people who do understand that if you're seeking out of the box, you may have to pay out of the box for it. So that's a challenge in terms of accessibility, but for us, it actually makes practicing of unconventional practice much easier.

Dr Andrew Greenland 31:31

So coming back to the word unconventional again, because it's cropped up a lot today, because you describe what you do as unconventional, I guess the mainstream medicine would perhaps regard what you do

Running Outside Insurance And Staying Safe

Dr Andrew Greenland 31:42

as unconventional. How easy is it to operate doing unconventional medicine in an institution in an institutionalized medicine country like the US? And how does that show up in your practice? It is difficult.

Dr Raymond Chang 31:54

One has to be careful. And I think that one has to not do one still has to stay clear and do what's appropriate and what's best for the patient. And for example, even if we prescribe off label, like I don't use phenbendazole, which is really a veterinary drug, and but a lot of patients out there are using phenbendazol, things like that. For example, for certain treatments, we do have patients like informed consent. That they understand we explain why you're taking it, what the side effects are, and you're free not to take it at any point in time. So these things are conventional mechanisms like informed consent. That we don't use things that are we follow certain rules. I think that's very important to do it in a in a above to do it properly. There are clinics that do funny things, a lot of them are in Mexico, so where there's less legal, less liability, etc. But again, I'm practicing here in New York, city, right under the shadow of the big kiss. So we do still we do what's proper, even though it's unconventional. So you have to steer a fine line.

Dr Andrew Greenland 33:14

Yeah.

Succession Challenges And Training The Next Wave

Dr Andrew Greenland 33:15

And what is the future? Where would you like Meridian Medical to be in, I don't know, 12 months' time? What are your plans and goals for the future?

Dr Raymond Chang 33:21

This is a challenge. This may be actually one of the biggest issues. Very few people are interested in entering this field. There are lots of people offering guidance on supplements and giving IV, vitamin, C drips, etc. But I'm talking about something more serious, something that's more academically grounded based on research and really looking for newer types of treatments. And but over the years, and I shared there are several other doctors like me in the US who do similar, have a similar practice. But I think we're all facing out we're older, and we're all facing the issue of no very few people want to come and learn this from us. It's not something you just learn from textbooks. You need the cancer experience. If you do cancer oncology, you need the experience, you need to know the conventional treatments. You should know the conventional treatments as well as the so you need to know that first, I think. And then the problem is that if you are a new graduate and you are interested in this, you will struggle to want to enter this particular area because it's just much cushier to join the staff at a hospital and have the benefit of pensions and other coverage in the US, like healthcare coverage, et cetera, et cetera. Whereas we are private, so and we're small. So you really need it's hard. You're passionate young doctors, and they come and they do some rotation to the office. They really like it. They think it's very exciting, something extra they can do for the patient. And academically, intellectually, it's very challenging to look into all these new things instead of just buy the book, just prescribed according to the standard of practice or protocol type way, protocolized way. But I understand the challenges. They're looking at career, they're looking at safety net in terms of professionally. We want to be with a bigger institution. So we have a problem of all the similar practices as I know, other colleagues doing the same thing, have trouble finding people to join and take over. So I don't know if we'll peter out, and then it'll be then, yes, there will still be integrative medicine, alternative medicine, in the sense the things I talked about. But that's a different, to me, that's a different, different focus.

Dr Andrew Greenland 36:04

Final question.

Hope, AI And The Price Tag

Dr Andrew Greenland 36:05

When you look at the future of oncology, what gives you hope?

Dr Raymond Chang 36:08

Oh, tremendous advances. Tremendous. It's just amazing. We've seen the turn, I'm fortunate to see have seen the turn from standard practices like chemotherapy and radiation migrating over to immunotherapies. I view that 20 years ago we started using cancer vaccines and things like that. But now it's everybody knows about it, everybody talks about it. So I think the science advance is going to be tremendous. So we I think we can solve this. The biggest challenge, and with AI, it will help us to solve this. I think the biggest challenge is finance. The cost of these new drugs or new treatments is stupendous. The latest one that came out, for example, we're talking $40,000, $50,000 per month of treatment. How can the system so can how can society afford these advances? Not only that, it creates tremendous inequality. More and more it's becoming, if you have money, you will be cured. If you are unfortunately in the third world, etc., it's whatever you cannot afford $50,000, even $5,000 or $500 a month. I'm sorry. For you, there's no treatment. Actually, that points us back to the importance of repurposed medicine school, not only because it's a whole different avenue of opportunity for treating cancer, but cost-wise, those alternative, those alternatives that repurpose drugs, the off labels, present is a much better option for people in the third world if the anti-parasitics are turn out to be very useful. For them, it's available and so maybe on that note, that's all I have to wish.

Dr Andrew Greenland 38:09

Raymond, thank you very much. It's been a really thoughtful conversation. I really appreciate how you're approaching it in the such a sensitive area with both openness and caution because this is not clearly about being unconventional for the sake of being unconventional. It's about asking whether care, cancer care can be more strategic, more personalized, and more responsive to the complexity of the disease and the patient. So thank you very much for sharing your insights and your experience. It's been a pleasure to have you on the show. Very grateful. Thank you.