Goose Poop and L-glutamine
Jacob Schor, ND, FABNO, AANP Board Member
Wednesday, November 12, 2014
by: Jacob Schor, ND, FABNO, AANP Board Member


Denver had its first hard frost about a week back.  If my dog could speak Hebrew she would have been chanting the S’hecheyanu prayer as we walked through City Park that morning with the frosted grass to roll in and most importantly the frozen goose poop.
This is the prayer that is traditionally said when tasting the first fruit of the season, back in that day before refrigerated cold storage and airborne produce shipments between hemispheres made fresh fruit a year round pleasure.  The prayer gives thanks to the Creator who has given us life and sustained us to be alive at this moment in time.  It is also said when performing certain commandments, at the birth of a child, at the start of certain holidays, at moving into a new home and other significant moments in life.  But most commonly it is said for that first taste of a fruit as it comes into season during the year, that moment when it is unquestionably good to be alive. 
In our dog Poppy’s mind, frozen goose poop is a delicacy of supreme pleasure. Flocks of geese fertilize the park lawns all summer, but what they leave is just so much bird poop.  Yet once it’s frozen, it’s like God Almighty, or perhaps it is Dog Almighty (but let’s save the discussion of dyslexia for another newsletter) has performed a miracle on high and opened a heavenly bag of dog kibble and littered it across the landscape.  This is no doubt how Moses’ hungry followers reacted to find Manna while wandering through the Sinai.  The dog was beside herself trying to vacuum up as much of it as I would let her.
Last night, barely a week after that frost, we had our first hard freeze.  The temperature dropped from nearly 70 degrees yesterday morning to nearly 16 degrees this morning.  The drop happened suddenly; I went to work wearing a light vest and left in a blinding blizzard, thankful that my dear wife had the foresight to bring my winter coat when she came in to the office at midday.
At about 10:35 in the morning a strong wind gusted up suddenly from the northeast, tearing the remaining leaves off the trees and blowing them horizontally so the air and sky were filled with blowing leaves.  The patient I was sitting with, along with his wife, sat watching this.  Actually we stood by the sliding doors that go out onto the deck behind the office to watch this display of nature.  It lasted five minutes tops and then stopped.  It was then that the temperature began to fall.
This morning, that first hard cold is in the air, the sort of chill that makes you aware you have nose hairs, the sort of temperature that prompted me to grab my flannel lined jeans off the shelf and put them on for the first time of the season, the sort of chill that makes me want to say my own S’hecheyanu, to be thankful to be alive to feel the seasons turn once again.
My patient yesterday who I stood by and watched the leaves fly by with was told a few weeks ago by his medical oncologist that to figure that at best he had 12 months to live.  Whether true or not, that kind of knowledge casts a poignant spell on every moment and on every interaction we will have together.  Life is no longer some seemingly endless possession; suddenly it’s just a short-term lease we have on everything we treasure and hold dear.  It makes everything precious.
The majority of the patients I’ve seen over the last dozen years have had cancer.  Colleagues sometimes ask me whether this isn’t too depressing a patient population to work with. Admittedly there is some accumulation of collected sadness somewhere in my subconscious.  I do find myself at times easily moved to tears but typically my experience is the opposite, a little something rubs off these patients, something of their vision of how precious it is to be alive gets left on my own vision and the world looks a little brighter as a result of our interactions.  They give me lessons and reminders on a daily basis on how to lead a better life.
In fact, the problem with these patients is they spoil me.  I sometimes have low tolerance for the complaints of the walking well, those patients with their whining complaints who aren’t even the willing to make minor changes in diet or lifestyle to get well.  Cancer patients in general are a motivated group.
This seems to be the experience of the many colleagues who specialize in cancer who I am in contact with through the Oncology Association of Naturopathic Physicians (OncANP) in our online chat rooms and at our conferences.  Working with this patient population is not draining as some doctors fear but rewarding.  We are able to provide these people with a great service and they in turn reward us with something equally precious.
I was thinking this morning while walking the dog, who was eager to go down to City Park again and see what God or Dog may have left her with last night’s snow, about the relatively recent research on the role cytomegalovirus plays in glioblastoma tumors, a role that is complicated, and how we might use knowledge from a few papers published in the last few months to our patients’ advantage.  [really, I do spend my time thinking about stuff like this]
It struck me that specializing in naturopathic oncology may no longer be adequate, that the knowledge base in oncology is growing so rapidly that it is difficult to keep up, that there will be a time soon in which we may need to specialize in particular types of cancer just to stay abreast of current knowledge and therapies.  It may be impossible to know everything we need to know about breast, brain and colon cancer, try as we might.
This is a curious thought in light of the fact that some of our colleagues still find fault in the idea of a naturopathic doctor specializing at all, thinking that we all should be generalists and that focusing on one area of disease goes against our tradition as family practitioners.  I find it hard to fathom this mindset.  People with cancer come to me and it is my fundamental moral obligation to provide them the best knowledge, information and advice that I can. Keeping up with such a rapidly growing field for me is difficult to say the least, and I must spend a significant percentage of my time trying to do that.  I can not imagine that a general practitioner would be able to keep up adequately.  If our prime directive is to ‘non nocere’, to do no harm, how can one offer advice without knowing what might hurt the patient, what might interfere with other treatments, what in itself might aid and abet a cancer tumor?
Perhaps we should be saying a prayer of thanksgiving as we see these shifts, a S'hecheyanu, that we have lived so long to knowledge and be able to share it with our patients....

Case in point, alternative practitioners have been suggesting to cancer patients that they supplement with the amino acid l-glutamine for decades.  Twenty, even thirty years ago data existed that this amino acid speeded recovery from surgery and reduced some of the side effects of chemotherapy and radiation, in particular mucositis, gastritis and neuropathy [i] (Savarese 2003).  There were even suggestions from rat studies that it augmented the effect of certain chemo drugs against certain tumor types [ii] [iii] (Rouse 1995, Klimberg 1992).
In the last few years, our belief that l-glutamine was a benign agent that did only good has been brought into doubt. 
Certain cancer tumors appear to undergo metabolic shifts so that they prefer glutamine as a food source, in particular ovarian [iv]  (Yang 2014) and pancreatic [v] cancers (Lyssiotis 2013).  In fact the “addiction” certain cancers have to glutamine is now considered a potential target for treatment; depriving the cancer of glutamine may slow its ability to grow [vi] (Vivanco 2014).  This is a change from a few years ago when we were encouraging patients to consume this amino acid and supplying it to them by the kilo. 
Scientific knowledge changes over time.  Sometimes it seems to shift as fast as the weather does here in Colorado.  Luckily OncANP members have been debating the pros and cons of using l-glutamine for several years and watching this shift in attitudes closely and with fascination.  It isn’t catching us by surprise. Still, what a change in attitude and opinion.  Perhaps we should be saying a prayer of thanksgiving as we see these shifts, a S’hecheyanu, that we have lived so long to see this new knowledge and be able to share it with our patients.

* Save the date for the 4th Annual OncANP Conference, February 13-15, 2015

Savarese DM, Savy G, Vahdat L, Wischmeyer PE, Corey B. Prevention of chemotherapy and radiation toxicity with glutamine. Cancer Treat Rev. 2003 Dec;29(6):501-13.   
[ii] K Rouse, E Nwokedi, J E Woodliff, J Epstein, and V S Klimberg. Glutamine enhances selectivity of chemotherapy through changes in glutathione metabolism. Ann Surg. Apr 1995; 221(4): 420–426.
[iii] Klimberg VS1, Nwokedi E, Hutchins LF, Pappas AA, Lang NP, Broadwater JR, Read RC, Westbrook KC. Glutamine facilitates chemotherapy while reducing toxicity. JPEN J Parenter Enteral Nutr. 1992 Nov-Dec;16(6 Suppl):83S-87S.
[iv] Yang L, Moss T, Mangala LS, Marini J, Zhao H, Wahlig S, Armaiz-Pena G, et al.
Metabolic shifts toward glutamine regulate tumor growth, invasion and bioenergetics in ovarian cancer. Mol Syst Biol. 2014 May 5;10:728. doi: 10.1002/msb.20134892.
[v] Lyssiotis CA, Son J, Cantley LC, Kimmelman AC. Pancreatic cancers rely on a novel glutamine metabolism pathway to maintain redox balance. Cell Cycle. 2013 Jul 1;12(13):1987-8. doi: 10.4161/cc.25307. Epub 2013 Jun 10.
[vi] Vivanco I. Targeting molecular addictions in cancer. Br J Cancer. 2014 Sep 30.

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