Episode 51:  Breast Cancer recurrence detection with caregiver turned oncologist Dr. Fumiko Chino

The Patient from Hell (00:00.789)
Hi everyone. I'm Samira Daswani, the host of the podcast, The Patient From Hell. Today I have a very special guest who we have been trying to get on this podcast. I think since we started this podcast, I have been fan -goaling this woman for many years now. I am thrilled to have Dr. Fumiko Chino on our episode. Dr. Chino, welcome to our podcast. Alright. So I'm going to start with not oncology, not cancer, not any of that stuff, but...

Fumiko Chino, MD (she/her) (00:22.27)
Thank you. I'm happy to be here.

The Patient from Hell (00:30.175)
We're going to start with fashion and style because you are, by a long shot, the most fashionable person I've met. Where did you come from? How do you shop? Give us some sneak peeks, please.

Fumiko Chino, MD (she/her) (00:43.678)
If you asked me this question, I looked at myself and I was like, oh, I'm not like, I need to tune it up for these, the ones that have video. Thank you though. I normally have bright colored glasses. I have like a big large statement necklace. I'm like low key Fridays right now. So no, thank you. What I realized is that like there was so much joy in fashion and...

There's a limited amount of joy in the world and I just want to promote more joy, so I'm a big fan of bright colors, bold patterns. It's actually one of the things that even my patients like consistently comment on the fact that they can't wait to see what I'm wearing and what kind of glasses I'm going to wear. And that actually really, really encourages me. It's not great for my pocketbook. I'm not going to lie, but.

I'm from the Midwest. Girl loves a bargain. So I'm on Posh Mart. I'm on the Real Real. I'm on eBay. I got, you know, my designers I like and what size I'm in. So I'm buying on a discount. And I only buy glasses now on like those crazy online glasses stores where you can buy a pair of glasses for $7 .99. So.

The Patient from Hell (01:58.869)
I'm sorry, you have to tell me this. My dad loves glasses, like he loves them, like he buys them in the dozens and he's the only other person I have, I know who kind of uses glasses in the way you do, right? Which is, I think it is like intentionally matching the outfit. In fact, sometimes it's the statement, right? Anyways, you have to tell me where, so I can walk around.

Fumiko Chino, MD (she/her) (02:22.782)
Yeah, so I'm not, I swear I don't, I'm not a stock owner in any, in anything to be honest. Very bad with my money. But I, most, my most recent glasses have been from a company called Zlull. And what happened during the pandemic is that I had so many interactions like in this triangle that we're currently interacting with

that I realized that these like big bowl glasses were gonna make a big difference in terms of just, you know, having a personality because I'm not able to be as warm and in person as I would be, you know, in a normal patient interaction. So I ended up getting kind of bigger and bigger glasses. So I started the pandemic with five pairs of glasses, which is already too many glasses. And I ended the pandemic with 13 pairs of glasses. Yeah, so big, big fan.

You know, we had to use our healthcare savings for something, right? We weren't going to the dentist, so.

The Patient from Hell (03:19.797)
I'm surprised you only have 14. I was expecting that.

Fumiko Chino, MD (she/her) (03:22.43)
It's enough. I really do. Whenever I travel for conferences, I pack my dresses and I pack my necklaces and I pack my glasses. I usually bring five or six pairs of glasses for five or six days. I like to have some options. You don't want to clash. And so when you're wearing a bright color pattern, you usually wear calmer glasses. So, you know.

The Patient from Hell (03:48.757)
I really don't. I'm horrible. This is my regular outfit. You'll see.

Fumiko Chino, MD (she/her) (03:54.046)
Well, I mean, there's the Audrey Hepburn, you know, everything looks better in black. I don't know if I have much black in my wardrobe at this point, actually. So.

The Patient from Hell (04:04.309)
I have a fun story for you so I used to live in New York and two roommates of mine decided to go to my closet one day and I think it was like 95 % black and they got really really upset.

Fumiko Chino, MD (she/her) (04:16.446)
I mean, that is a classic New York thing though. Like if you are on the streets of New York, it's black, black, black, black, black, black, black. I mean, it is a universal. That's just, you know, I got to walk my wild way. So, you know, I grew up a half Japanese kid in Indiana. So I was already standing out at six foot from the time I was in fourth grade. So, you know, like I just, I decided to embrace it at some point.

The Patient from Hell (04:45.813)
That's remarkable. Okay, I love this. How did you end up in oncology from growing up in Indiana?

Fumiko Chino, MD (she/her) (04:52.35)
Yeah, no, well, I didn't ever plan on being a doctor for sure. I went to, you know, I well, I went to the university that was free that was farthest away from home. So I went to Houston, Texas for my undergraduate and I got a bachelor's of fine arts in studio photography slash digital imaging. And so I spent years in the art scene. I was an art director of an anime company.

And so I never really planned on being a physician at all, much less an oncologist. I really did get pulled into it kicking and screaming. In an alternate timeline, sliding doors, a phenomenon I would be just happily doing something else right now that would probably be very arts focused.

The Patient from Hell (05:42.453)
Out of curiosity, what would we be doing? It's an anime company.

Fumiko Chino, MD (she/her) (05:46.814)
Yeah, I don't. You know. You know, honestly, I think I'd be managing an arts nonprofit right now. I think that that's where my alternate skill set may lie. I would probably still be writing grants, but they would be for, you know, putting on performances or opening up like community outreach, that sort of thing, and not anything to do with cancer. But here I am.

The Patient from Hell (06:11.285)
Uh, Dr. Chino, did you know I studied art history?

Fumiko Chino, MD (she/her) (06:15.898)
No! That's cool!

The Patient from Hell (06:18.389)
My undergrad was in art history.

Fumiko Chino, MD (she/her) (06:21.022)
Yeah, I mean, it's funny how you end up, I have to say this background in arts has really, it's served me pretty well as an oncologist. I think it gives me a different perspective, which is for good or for ill. I know a lot less about the Krebs cycle and I know a lot more about communication, which is honestly, most of art is about communication, or that's how I'm going to spin it for this podcast.

The Patient from Hell (06:49.077)
Don't forget to do that.

Fumiko Chino, MD (she/her) (06:51.716)
So yeah, it's been a wild ride, but I was just happily, you know, anime, Sailor Moon, you know, we were working on our, launching our anime magazine when my fiance was diagnosed with cancer. And that's really kind of what pivoted my world into a medical society concept, all engulfing catastrophe.

The Patient from Hell (07:19.541)
Are you comfortable talking about what happened then?

Fumiko Chino, MD (she/her) (07:23.87)
Sure, I mean, I feel like it's part of my origin story, unfortunately. But yeah, I always want to start with just like, I was an independent person before cancer. I'm an independent person after cancer. I feel like so many patients and survivors and caregivers and...

Even providers, they get defined by being like a cancer patient or cancer survivor. We're all whole ass human beings outside of cancer. But anyway, my fiance at the time, then husband, was diagnosed with a sort of fast growing cancer, very common for the AYA population or, you know, like anyone below the age of 40, you know, kind of face a lot of barriers to diagnosis, tend to have more aggressive cancers.

And, you know, we kind of struggled through the healthcare system. We had a lot of costs related to his care and made these difficult decisions that a lot of young people have to make about what to do with your career. You know, what sacrifices you're willing to make, you know, how do I pay for this? How do I like keep the lights on? What am I willing to give up really? For a period of time, we even moved in with my parents. That was fun.

And eventually we ended up in Michigan, which is where he died in the hospital. And I was, we had sort of just moved there. And so then I sort of just stubbornly stuck it out there for another year and a half with like very little support system before moving back to Houston and getting started with the process of thinking about medical school and kind of like what I was doing with my life.

The Patient from Hell (09:16.213)
Can I ask you something here? So here you are in Michigan trying to decide how your life changes. Why did you go into medicine versus, I don't know, start a nonprofit?

back to the community.

Fumiko Chino, MD (she/her) (09:31.55)
Yeah, I think stupidly thought that I had something to contribute based on my experiences, based on my passion to help people, based on what I perceived as the gaps between care that's intended and the care that's delivered. And so it was really just ego that brought me into medicine. I felt like I could help

maybe change the story a little bit. I felt charged. How about that? I felt like there were some discrete things that happened along my husband's course that probably could have been better. So, stupidly, I thought I was the one to do it.

The Patient from Hell (10:18.549)
I don't know how stupid that is. I think it's pretty cool. I, for example, am super grateful that you're a doc on the other side.

Fumiko Chino, MD (she/her) (10:21.246)
Mmm.

Fumiko Chino, MD (she/her) (10:25.182)
Well, I mean, I think some of the things happen with kind of your own life, right? Which is like you get a huge derailment related to cancer and then you kind of have, you're at the end of it, although there's no end of it. There is no end of it. You're at the end active treatment, I'll put that in quotes. And then you're like, how do I put the pieces back together to form something that assembles an idea of a future?

And I think some people have a harsher time of it. And it's like sort of like how hard did you crush the cookie? You know, and it can be related to, yeah, toxicities of treatment, the intensity of treatment. But also, you know, like we all come to different, you know, we're not we're not all given the same size cookie to begin with. So how you try to kind of put it back together is this analogy is getting very frayed.

The Patient from Hell (11:23.029)
I I I was trying, I was like, Vaze, Vaze gonna work? Cookie, I mean, how do you put a cookie back together? I was like, ah, doc, this is gonna be a hard one for me to summarize.

Fumiko Chino, MD (she/her) (11:30.716)
No, no, yeah, this, I mean, I spin out narratives all the time for my patients. I'm trying to give them examples and I'm like, it's like car insurance. You don't get into an accident and then buy car insurance is how I describe radiation all the time.

The Patient from Hell (11:45.909)
Huh? No, no, you'll have to explain that to me. I'm like what? No, no, I didn't follow -

Fumiko Chino, MD (she/her) (11:49.342)
Oh, I always say that. So when someone's had surgeries for something like breast cancer and the tumor has been removed, what I'm doing is treating single cancer cells that may or may not be there. And the problem is, is that I don't know if they're there. And so it really is like an insurance policy. And you don't buy an insurance policy after getting into an accident. You get it now and you hope you never need it. And that is the unsatisfying result of

you know, cancer treatment, after chemotherapy, after radiation. The only way we know it works is if you live the rest of your life and you die of something else.

The Patient from Hell (12:29.621)
Yeah, yeah, it's true. It's true. Huh.

Fumiko Chino, MD (she/her) (12:33.278)
And so it's, you know, it's weirdly unsatisfying. It's also like incredibly hopeful, which is like, I'm going to take credit for, you know, like, like, you know, you're 100 years old and you're living your best life. I'm when I'm 100, I'm going to be like, you know, with with my cane, like, you know, like stealing groceries or whatever. But, you know, when I die, I sleep at 100. I consider that a successful life. We all got to go sometime. But yeah.

The Patient from Hell (12:53.813)
Thank you.

Fumiko Chino, MD (she/her) (13:03.262)
That's the future I'm planning for all my patients and for myself. We're all going to be stealing groceries at 100.

The Patient from Hell (13:06.933)
I like it.

The Patient from Hell (13:13.077)
There were two things you said that I wanted to sort of underscore and then if you have time to come back to. The first was kind of the motivation of like, the care that is intended is not the care that is delivered. And I think that is such a powerful phrase. And I think it's such a well encapsulates the reality of cancer treatment. And honestly, like the work we do as well, I think it's exactly that, right? There's this gap. I'd love for you to talk a little more about that.

Fumiko Chino, MD (she/her) (13:33.086)
Yeah.

Fumiko Chino, MD (she/her) (13:38.686)
Yeah, absolutely. I think despite our best intentions, despite all of the privilege that we have, you know, I deliver care in the United States, one of, you know, if not the wealthiest countries, you know, certainly a country of privilege where we have every bell and whistle, and yet not everyone can access those bills and whistles. Not everyone has

the capacity for receiving the highest quality of care. And even when I am able to offer the best, you know, every bell and whistle, you know, how it actually is, you know, delivered to the person and kind of their capacity to receive it can be quite variable, right? And, you know, again, communication is a part of it, right? But access, affordability, these are all like large barriers.

You know, one of my most well -lauded studies is on parking costs, which is quite frankly like a really stupid thing to study. Like, why would parking be a barrier to anyone? It's parking. But it really hit a nerve because patients are like, I hate it. It doesn't even matter if you're a billionaire. Billionaires hate paying for parking too. But what's truly insulting is that people who actually can't...

The Patient from Hell (14:46.965)
I did.

Fumiko Chino, MD (she/her) (15:06.718)
get the care that they really need in the facility that would probably serve them best because of a silly barrier like parking.

The Patient from Hell (15:16.437)
I fully, fully, fully agree. The person I met more than just about anybody else in the 18 months of treatment was the parking attendant. He and I, he was a buddy of mine. He literally, like, I would come in, if he wasn't there, someone else was there, I would actually be really sad because he would talk to me every single time I pulled up my car and every time I left and then,

Fumiko Chino, MD (she/her) (15:29.342)
You form those great relationships, right?

Yeah.

The Patient from Hell (15:45.685)
nine or ten times he would waive the parking fee for me. And it was just the sweetest, nicest thing because when you have to pay the whatever five bucks and I'm privileged that I can afford to pay the five bucks...

And I can walk, but to have a patient park, pay, and then have to like somehow figure out how to get out of the car, make their way through all of the rigmarole to get to the right spot inside the cancer treatment center was just, I used to watch that. It used to break my heart and he would make that easier.

Fumiko Chino, MD (she/her) (16:25.47)
Yeah, it's actually, it is shocking how much is that full. It's the full companion of people that make a huge difference for your care. And I think, you know, providers, doctors, we think, oh, it's, it's my voice that matters and it's not like it doesn't, but I think we underestimate how the full package makes a difference. The parking attendant, it's the person who checks you in. It's the person who takes your vital signs. It's the person who draws your labs. And it's the entire experience that can make a huge difference. And

It's funny, you know, like there's some amount of corporate speak that goes on here. I found out recently that we call it a warm welcome at MSK. We want a warm welcome for everyone, which sounds like, again, it's a little corporaty. But I love that concept, which is that we are trying to envelop people in warmth because that heated blanket that, you know, whatever, like person offering you a coffee,

it makes a big difference, or alternatively, the sour note can ruin your whole day.

The Patient from Hell (17:34.357)
I fully, fully, fully relate. Honestly, this company wouldn't be, like we have a company, we wouldn't be doing anything had it not been there was a survivor. Actually, I think it was a mom of a patient going through it who sat in hand -knit hats for all the patients going through chemo. And this woman, I don't know who she is, she left it at the reception.

And I remember it was just like, it was COVID, all of the nonprofits had shut down, all of the sort of like, supportive care spaces had shut down, getting stuff was hard. This was like early COVID, first month of lockdown. And I had just lost my hair. Couldn't get a wig because everything had shut down, right? So like, and I had to go to work and it was cold. Like the thing they don't tell you is it like when you don't have hair, it is cold. You get cold a lot. Anyways, I walked into the system

and the receptionist hands me a hat. And I was so happy. I was like, oh my God, here is this hand-knit hat that I didn't even know I needed, but has become basically a safety blanket for the next 18 months of care that somebody I've never met this person completely transformed the full experience for me. Anyway, I, yes, all of this to say that I fully, fully agree.

with the statement you just made.

Fumiko Chino, MD (she/her) (19:02.248)
It's that act of kindness that man, I mean, this is true outside of oncology, outside of critical illness. I mean, like just being kind is just like such a huge thing. I mean, I have to continually remind myself even for people who I consider unkind that like, okay, like, I don't know what's happening in their life. Probably something else is, you know, driving this. I have to give some compassion to them to, you know, to try to.

So what I'm looking for, I don't know, put good vibes out into the universe, hopefully good vibes will return, you know, like if you're gonna be kind of munchy -crunchy about it. But man, like just selfless acts of kindness, like, man, you made me cry with that hat store.

The Patient from Hell (19:44.757)
I'm sorry.

Fumiko Chino, MD (she/her) (19:46.654)
But I love it. And again, that person, I'm just going to be totally gendered and say that it's a woman. That person who knit you that cap. You know, it could be that no one else cared about the caps, but it made a difference to you. So.

The Patient from Hell (20:03.925)
Dr. Chino it's why I made the planner. I'm not joking. I am not joking. I fully, fully, I normally don't say this because it's such a long, I normally don't go into this level of detail. It's just we're talking about it. It was why I made the planner. Because here was this person who had never met me, who somehow knew that that was a thing I needed at that point in time. And it wasn't a nonprofit, it wasn't this big thing. It was just this moment of like,

Fumiko Chino, MD (she/her) (20:06.686)
Hahaha!

Fumiko Chino, MD (she/her) (20:18.27)
Mm -hmm.

Fumiko Chino, MD (she/her) (20:26.878)
I mean that's...

The Patient from Hell (20:32.127)
unanticipated need of someone going through it. And I was like, Oh my God, this person can do such like made such a big difference in my life. If I could do something using my skills, like I can't knit to save my life. That just, I don't think that would be how I give back. But like, I can, I can like make something that has value and give it back. And like, honestly, that was the moment I was like, Oh my God, that is exactly why I need to do this. And just anyway.

Fumiko Chino, MD (she/her) (21:02.398)
That's the foundation of my career, this concept that maybe we could like, we could make care or treatment or the journey, again, air quotes, the journey of cancer, if we could just make it a little easier. Like, and I usually, for mentally, you know, 1% easier is my goal, 1% easier. But the thing is that if you make care 1% easier for a million people, you've made a profound difference in the world, life.

The Patient from Hell (21:02.613)
Thank you so much.

Fumiko Chino, MD (she/her) (21:32.478)
And I think classically, at least as cancer doctors, we're constantly like, oh, I want to find a cure for cancer or whatever. But I just want to cure more cancers that are curable, or I want to provide more comfort to people who are suffering. I want to envelop people in warmth when they might have been a little cold. And that's really the whole concept that drives

the kind of research that I do and the care that I provide. I'm just like, I just, I want to help a lot, but barring helping a lot, I want to help a little, you know.

The Patient from Hell (22:12.021)
Do you know that's a mission for a company?

Fumiko Chino, MD (she/her) (22:14.342)
Help a little.

The Patient from Hell (22:15.937)
No, it's just make the cancer experience just a little easier. That's the mission. Because I think we got it. Yeah, I didn't think we did, which is why I said it. And I was like, huh, this is off. And for what it's worth for all the people listening, this was not planted at all. I can promise you that. But it really is. I think we were surrounded by a lot of companies trying to do what I would put in the bucket of like...

Fumiko Chino, MD (she/her) (22:20.03)
Yeah, yeah, yeah. I did not know that.

The Patient from Hell (22:44.539)
moonshot right like let's transform oncology let's yes all that is needed I'm fully supportive but it honestly it's the small things that i needed first it's small stuff first

Fumiko Chino, MD (she/her) (22:57.31)
It's the hat. It's the hat. It's the parking. It's the warm blanket. It's the, you know, it's the map, you know. Mm -hmm. Yeah. It's the, it's the packet of saltines. The saltines. Oh, they are clutch.

The Patient from Hell (23:05.653)
Yeah, that was awesome. Yeah, exactly.

The Patient from Hell (23:16.597)
I will say I am a little, I'm at the point where saltines equal trauma for me, so I am not at saltines equal happiness right now, but at some point in my life that may transform into, you know, happiness again, but not there yet.

Fumiko Chino, MD (she/her) (23:26.878)
You can come full circle on it. I'm sending you wishes that you can reclaim saltines. I can't, based on my own PTSD, I can't watch the movie Dreamgirls. I cannot hear This American Life and I can't see the Oscars.

The Patient from Hell (23:34.463)
Thank you. Thank you.

Fumiko Chino, MD (she/her) (23:54.526)
Those are my triggers.

The Patient from Hell (23:56.181)
I can't write it. I have my list. My radiation playlist cannot ever be played again. No song in my playlist can ever be played again. There is a list.

Fumiko Chino, MD (she/her) (24:05.15)
Ha ha!

Fumiko Chino, MD (she/her) (24:13.214)
God bless America.

The Patient from Hell (24:18.197)
Normally when we talk about science and research, it's very easy for me to be very, you You know, like, here are my clinical questions for you, doc. This one.

Fumiko Chino, MD (she/her) (24:27.07)
Oh, I'm happy to answer those. I mean, honestly, as a radiation oncologist, what I do is often, I mean, I'm basically aiming invisible light into people to kill cancer cells that may or may not be there. I mean, it seems like very woo woo. So I'm happy to explain that. But in reality, you know, I'm also happy to talk about fashion.

The Patient from Hell (24:55.637)
I have never heard a radiation oncologist call their work woo woo woo. I appreciate it.

Fumiko Chino, MD (she/her) (25:04.19)
It seems like magic, right? I'm trying to break cellular DNA and I'm breaking all of the DNA. It's just that your own cells repair their DNA. It seems bananas, but it works. And it works, you know, enough times to save lives. I'm always really honest with, with.

my patients and I'm just like, the problem is is that I know I'm like of five women I'm going to save potentially one person. The other four may or may not needed it, you know, it's really just it's to save that one person. And I don't know if that person is you, but I don't want to take the chance that it's you know, like, it's like you wouldn't play Russian roulette with one live bullet, you know, when that bullet's cancer. So I want you to take the treatment.

But in reality, if you walk out the door right now, you'll probably be okay.

Fumiko Chino, MD (she/her) (26:10.302)
I mean, probably is not, you know? Like, that's the problem with large numbers, right? Statistically, it's probably not gonna happen to you, but I can't tell you that it won't. It's like a really good thing or a really bad thing. And that's what's really frustrating. Numbers are imperfect, you know?

The Patient from Hell (26:30.933)
The reason you see me pause on that is I think I fall into the patient camp that really goes deep on numbers. And I really struggled with the decision you're talking about. I had a phenomenal Radong. She's amazing.

Fumiko Chino, MD (she/her) (26:39.772)
Hmm.

The Patient from Hell (26:49.013)
And we had a long discussion on local recurrence, distant recurrence. We went like deep into the rabbit hole of like stats and eventually, honestly, it came down to do I trust her?

Fumiko Chino, MD (she/her) (27:03.806)
Yeah.

The Patient from Hell (27:05.109)
Because it is, it is what you're describing. Like radiation does feel like this. Because you don't even feel the if, well, I shouldn't say that. I definitely had really bad reactions to radiation. Very bad. Had to stop. Bad, bad reaction. The grade three level symptoms, bad. But it does, you don't feel it in the way you feel chemo, right? Like chemo is like, I'm gonna punch you in the face. You're gonna get knocked out. Radiation is like, well, I'm gonna boil you in water very slowly.

Fumiko Chino, MD (she/her) (27:07.166)
Yeah.

Fumiko Chino, MD (she/her) (27:26.812)
Mm -mm.

The Patient from Hell (27:32.969)
very slowly you won't even you'll think it's a sauna you will love it and then it's gonna come right so just very different like

Fumiko Chino, MD (she/her) (27:38.846)
Yeah. Yeah.

I mean, I always say it's different experiences. So people come to me after, for example, four months of chemo and they're like, well, I got through chemo, so I'm ready to go. And I was just like, well, most people do easier with radiation than they do with chemo. But there's occasionally people that do way worse with radiation. And I can't tell you that that won't happen to you. But most people do okay. I say okay, reasonably well is the other thing I'll say. I say at the end, you're not going to want anymore. I can guarantee you that.

No one signs up for bonus rounds of radiation. And even during treatment when people are like, I'm doing great. And I was just like, you are. I'm gonna warn you over the next week that these things are probably gonna get a little worse, but it's okay. You we're gonna, you know, one foot in front of the other, but yeah, it's, it seems it's, you know, it's all proportional risk. And again, this kind of new phrase in medicine called shared decision-making, which is that,

I think if you're fully informed, like these are the risks of my treatment, these are the benefits, this is kind of the recovery period, it can make a big difference in terms of people feeling comfortable that it's the right decision for them. And that concept of kind of decision regret, like I did this thing, I didn't really wanna do it, and now I kind of like have all these side effects.

You know, I don't think it was the right thing for me. Like, that is just the worst. And, you know, our treatments don't always work and some people have really bad reactions to them, you know? I've had people lose all of their skin and it's not common, but it can happen. And so I tell that to every person. I was like, it could happen to you. And that stinks. Apparently it happened to you.

The Patient from Hell (29:30.261)
Oh, it happened. It happened.

Fumiko Chino, MD (she/her) (29:34.918)
Yeah, I mean, and it's just so disruptive to your life. I mean, outside of the daily treatments, like that's obviously disruptive, but like, you know, being in pain or being uncomfortable or not being able to sleep well, sleep is truly underappreciated in oncology. It's just, it's insult to injury, you know?

The Patient from Hell (29:58.389)
I have a hilarious story actually about the moment in time we're talking about because my tumor was my right armpit ,and so I had radiation in the whole breast but also in the armpit and it was like, I'm forgetting what it was, like focused radiation, like specific rays focused on that area. So I had the like, all my skin came off and like everything, there was my armpit so I couldn't put my arm down. And the hilarious part of this whole thing is me

deciding this, this is my decision. My family's like, we should go to Joshua Tree over like one of the long weekends. COVID-19, you know. So we drive to Joshua Tree, have family, I have family in LA, except I can't put my arm down. So my arm is above my head the entire ride. I got to a point where I couldn't keep a T -shirt on, so I was like in a bra only. I probably shouldn't be saying this on a podcast.

But you know, not exactly pretty. The funnier part of this whole thing is that was when, so I was working at a COVID-19 medical diagnostic company at the time. And we got FDA approval for our device the same week that this was happening. And I was part of the launch team and I had to like sit and edit all of our press releases and all the content that had to go out and the instruction material, but I couldn't type because I couldn't put my arm down.

Fumiko Chino, MD (she/her) (30:58.566)
Mm -hmm.

The Patient from Hell (31:26.165)
So I got very used to using voice AI. Voice AI became a really good friend of mine during radiation. And I have to enable voice AI got me through that week. It was highly entertaining. My family looks back and like, you are a nutcase woman, completely nuts. But we'll ignore that part of it. But you know, that's pretty rough. Like I was not ready for that to say the least.

Fumiko Chino, MD (she/her) (31:48.862)
Well, we do what we do to have some normalcy, to have a job, to go on vacation to Joshua Tree, even if it's like we're the insane women wearing a bra, you know, with our arm up, right? Because like, it's like to not have not taken the trip or to not like, you know, have a job, like, you're just fully embracing being, you know, a cancer patient at that point. Like it defines who you are and you're obviously not, you know.

It's actually really funny because when I ask, when people tell me like, well, can I work? Should I work? And I'm like, in my opinion, you should because it helps give you a schedule. You know, like if you can take the time off and you can afford it and you want to, yes, absolutely. But you should at least do something with your day. Because I think otherwise, number one, your mind goes to dark places. So we're not built to just sit around the house. But, you know, unless we're independently wealthy, which I'm not, and most people aren't.

The Patient from Hell (32:46.741)
Yeah.

Fumiko Chino, MD (she/her) (32:48.422)
We're used to having accountability. We're doing this, we've got to plan for this. That's our personalities, that's our hustle economy. And to suddenly be in this sort of rudderless sea where you can only think about cancer all day is not necessarily great for you either. I mean, everyone's different. Definitely people have luxuriated in their time off, but it's not really vacation.

You know?

The Patient from Hell (33:19.121)
No, not a vacation. Not the kind you want to go on anyway.

Fumiko Chino, MD (she/her) (33:24.67)
Yeah. I mean, it's funny though, because classically you're like, I wish I could take time off, but I have to work. And I'm just like, in some ways it's actually better for some people, because again, it's just like, you have something else, you have other shit to do. I can't, I'm sorry, I can't be sick right now, I got other shit to do. You know? Like, I can't, I can't feel sorry for myself, I got other shit to do. You know? Like, I can't, you know? Not that you shouldn't also indulge in that sometimes.

The Patient from Hell (33:54.229)
Oh, it's totally true. On that note, I am going to talk to you about research because that was one of our themes for the podcast. And I'm reminding myself that I will not forget again that we should talk about this like I did in my preppy multi-U. Okay. So I'm guessing you read the study. This is a PICORI funded study. I'm going to just quickly summarize the study and then I'd love your thoughts on it. Unfiltered thoughts. Okay. So.

Fumiko Chino, MD (she/her) (33:58.206)
Oh sure.

Fumiko Chino, MD (she/her) (34:17.662)
Sure.

The Patient from Hell (34:22.229)
Quick summary and you can correct if I'm getting the summary wrong too, by the way, if I'm, I'm interpreting the results wrong, please do correct me. But the way I read it is essentially many types of breast cancer. We have triple negative breast cancer, HER2 positive breast cancer, hormone positive breast cancer, just as a sort of gross approximation of three subtypes for women, mostly sometimes men, but women mostly with triple negative breast cancer or HER2 positive breast cancer.

stage two or three in that range, they are more likely to benefit, not, I shouldn't say that, they are likely to benefit from active surveillance, i .e. imaging, because asymptomatic imaging is associated with a lower risk of death versus waiting for your symptoms to show up and then go get tested. Is that a fair?

Fumiko Chino, MD (she/her) (35:14.078)
I think we need to provide more context, but sure. I don't think that's exactly what this study shows. You're kind of leaping ahead from a, so I think this is the problem with research, right? And we saw this during COVID, right? We saw the sausage being made. People were like, the research shows this. And then other people were like, the research does not show that. And people are like, wait, it's research. How could it be wrong?

The Patient from Hell (35:15.341)
Alright.

The Patient from Hell (35:30.261)
I'm ready.

Fumiko Chino, MD (she/her) (35:43.166)
And I think that there are just many different types of research and kind of what we consider the gold standard, like the best type of research wasn't being done during the early COVID pandemic. And this research also does not represent like kind of the gold standard. So it's retrospective, meaning that they went back and they looked at all of these charts of patients who got imaging for either asymptomatic surveillance, meaning again, just routine scans versus we're not getting routine scans.

And I think it's interesting the population that they focused on, which is stage two, stage three, patients with breast cancer. So stage one, I think everyone agrees, shouldn't be getting asymptomatic surveillance. Too low risk. Should not be getting, no. Stage one, yeah, absolutely. Your chance of catching something that has nothing to do with cancer, but then will lead to a diagnostic cascade that will then eventually hurt that person is much higher than your chance that you're gonna find something that's actually gonna make a difference for them.

The Patient from Hell (36:24.533)
Hmm. Should not be getting.

The Patient from Hell (36:38.773)
you

Fumiko Chino, MD (she/her) (36:43.19)
Stage four cancer, everyone agrees, you should be getting imaging, not surveillance. They're like, you know, they need imaging to make sure that their treatments are still working and that they're not having, you know, new problems, et cetera. It's kind of the people in the middle, right? And the current guidelines are that you should not get any imaging unless there's a problem, which is what I explain to my patients all the time when I, you know, say, okay, we're done with treatment and they're gonna say, okay, when is my next scan? And I'm gonna say, never, hopefully.

Yeah, I mean, they're going to get mammograms images of the breast, but of whole body scans. I say hopefully never because I would only be imaging you if you have a problem. But it does highlight the fact that there are definitely people who are not quote unquote following guidelines. So there were people getting asymptomatic scans in this group of people. And those, you know, that's even though their guidelines say you shouldn't, there's people who do it.

Typically for people who are getting guidelines against scans, or getting scans against guidelines, sorry, I'm gonna, this is like a tongue twister. They are people I'm worried about. You know, like they are people I'm worried about. There's a reason why I'm getting that scan even though you have no problems. And so it's someone, for example, who I treated as a stage two or stage three, but they had this weird little bone thing.

And like, I treated them for a cure, but I'm just like, I want to keep an eye on that bone thing. It's probably nothing, but I don't trust it. So we're just going to continue scanning you to track that. Or like, there was this lymph node. It was over here. Technically, you know, I treated it, but I didn't think it was involved. But you know, I just want to make sure it's not doing anything funny in the long run. So I would say that probably those patients were a little different, even though on paper they look the same.

But what the study found is that those people who have kind of more high risk histologies, the triple negative patients, the patients with HER2 positive cancers, they did seem to benefit from those scans. The hormone positive patients didn't seem to benefit from any asymptomatic scans, which is the bulk of patients with breast cancer. So it does kind of point to this idea that...

Fumiko Chino, MD (she/her) (39:02.47)
You know, let's just say you had stage three breast cancer, you had a lot of lymph nodes involved, you were treated for cure, you're no evidence of disease, you had triple negative breast cancer. I really, you know, like it kind of does make sense that like you're saying I'm only gonna get a mammogram once a year for the rest of my life, that seems bananas. I'm like, yeah, okay, okay, I kind of see it. Like maybe we should be, you know, ordering more frequent scans on you. So it is like

proof of evidence of that, but then the next step is then to confirm these findings, which is that you do the trial. You don't go back, look through time. You actually say, these are the populations we're studying. Let's order scans for these patients, do standard of care. Standard of care in this case would be no scans, unless there's a problem, and actually see if this makes a difference in terms of their outcomes. Because otherwise, you're just like, there's so like.

You know, it's kind of apples and oranges, right? You're like looking back on what is essentially two different patient cohorts. They look the same when you're like doing a chart dive, but there was a reason why this person got a scan and this person didn't get a scan. Does that make sense?

The Patient from Hell (40:06.709)
Okay, it does. I have a few questions for you. So the first is just a clarification because I think when we are saying scan, I at least I think we need to differentiate that versus your annual mammo right? Because a mammo invokes a scan in quotes, right? So can you just differentiate that for us?

Fumiko Chino, MD (she/her) (40:11.198)
Go for it.

Fumiko Chino, MD (she/her) (40:19.614)
Mm-hmm.

Fumiko Chino, MD (she/her) (40:25.022)
Sure, and one of the great things about this study is that it looked at sort of a more modern cohort, meaning like a group of people kind of in the modern era, because scans have really changed. So it used to be scans when we talked about surveillance, where like a chest x -ray and an ultrasound, like that is like the most basic imaging that you can get. We hardly ever do chest x -rays and ultrasounds for anything cancer related nowadays. It's just the...

You know, it's like a low quality imaging, what we call. And then what we're often talking about is kind of full body, like kind of from your chin to your mid thigh scans, like a, you You know, a cat scan, I'll call it a CT scan or a PET scan, which is a CT scan plus a metabolic component, which were kind of things that consume a lot of sugar light up bright. There's also full body MRIs, which we very rarely use, although apparently there's some.

people showing for them on Instagram that you should be buying them out of pocket, $2 ,000. And those are separate than what we consider just routine imaging of the breast, which is typically mammogram slash ultra cellulose MRI of the breast. And those are really, you know, we have fairly good data about that in terms of there are some people who, you know, even after a breast cancer diagnosis are going to benefit from more intense screening, meaning like,

every six months, or some people really don't benefit from that and they should just go back to annual images, but the images maybe should be a little better. You know, should certainly be, you know, a 3D mammogram or even maybe a contrast enhanced mammogram, which is a newer technique. So there's quote unquote image of the primary, which in case of breast cancer would be the breast, and then there's kind of like, You know, surveillance of the rest of the body.

The Patient from Hell (42:15.605)
I see.

Fumiko Chino, MD (she/her) (42:18.216)
Definitely people need imaging of the breast. If you have a breast, you should probably get it imaged. But that is something I actually have to explain to people at the time, which is like, if you've had a mastectomy, there's not a role for a mammogram for you anymore, which is really frustrating for people who were really used to getting mammograms, and sometimes joyful for people who are really used to getting mammograms. But...

It's a distinction, right? Because I can't tell you how many people have finished their treatment and they're like, okay, when am I gonna get my next scan doc? And I'm like, it's gonna be in 10 months and it's gonna be a mammogram. And they're like, I can't believe you're not gonna get imaging next month. How do we know that this treatment worked? I was like, well, as I said, this is insurance. You really don't want an insurance payout, right?

The Patient from Hell (43:06.677)
Yes, Yes, yes, yes. I fully relate to that mindset though. I really struggle with that. Always struggle. It's brilliant.

Fumiko Chino, MD (she/her) (43:10.91)
Yeah, it's hard. I mean, I tell people all the time, I would get a mammogram every month if I had evidence that it actually would help you. We would be here every month but it just leads to scanxiety. It just leads to additional money and copays and time. And it doesn't seem to improve outcomes. As soon as we have a group that it improves outcomes for, we should do that. And as soon as you tell me there's a problem, something funny,

I don't know what's going on, but I'm feeling pain here. I'm gonna bring you in, I'm gonna examine you, and if I can't explain it, that's when you're going for imaging, you know? So, if for nothing else, just for my and your peace of mind. So, I was like, I have a very low threshold than if you have a complaint. And I think understandably people are like, no, so if I just say I have pain, what good is imaging?

The Patient from Hell (44:04.469)
I will tell you that that low threshold mucked with my head a lot. I'll tell you why, because it's really hard to differentiate good symptoms from bad symptoms. There's no good or bad symptoms, but like it's hard to differentiate a symptom that qualifies reaching out to my clinician versus not. If I have a headache that goes away in an hour, does that mean I should, MyHealth message you? I'm guessing not, but I think it's just as if they're going through the gradations there.

Fumiko Chino, MD (she/her) (44:10.366)
Mm.

Fumiko Chino, MD (she/her) (44:33.822)
Yeah, no, and that, I can't tell you how many times I've heard that. And so whenever I, you know, when people are completing radiation, I have like my little spiel and I'm like, this is how you should take care of your skin. This is when you should call me blah, blah, blah. And I was like, okay. So for the rest of your life, you're going to have weird things happen to you because we all do. Like all of our bodies are full of white light, you know, like, you know, like we're all beautiful butterflies. And that means that like something's, you know, whatever it's going to, something random is going to happen. You're going to have a pain in your knee or in your back.

I'm like, so you're constantly like, you're like, my body already betrayed me once, where is it going to betray me again in the future? Right? So I just want to tell you the things that you should actually be worried about versus the things that you could potentially safely ignore for now. And it's essentially any symptom that's new that gets worse over time. That is what I want to hear about. And I'll give you an example of like, I had back pain last week.

I slept in the bed wrong. Who really knows what caused it? I don't care. It went away. That is not something I need to hear about. But back pain that is still there a month later is to the point in which you're taking Tylenol every day. That is not normal. Same thing with a headache. I had a headache. It went away. Don't know what caused it. Maybe sinuses. But I've had a daily headache. That is not normal, right? And so I think it gives people that reassurance of like, oh my goodness, like...

Not every cough is cancer in my lungs, right? Because most coughs are allergies. But again, even if it's not allergies and it's like heartburn, something that can cause chronic cough, you probably shouldn't ignore that for a month and a half either. So if you've had a cough for a month and a half, even though it's probably not even cancer, someone should be addressing that. So I think it helps to give people guardrails

and you know, like give people, I give people permission to be mad all the time. I give people permission to be mad at me all the time or to be mad at their friends or family. I was like, they don't know what you're going through. You look totally normal. And I say that in a good way, but you don't feel normal. Like, and again, I know you don't want to look sick, you know, but because you look so great, people don't know,

Fumiko Chino, MD (she/her) (46:54.782)
and they think that you're done with your treatment, for example, and they're like, okay, you're better now, let's get back to life, and you're still internally scarred. It's okay to just be like, I need a minute, or I need to ramp up, or I need to have a break. It's okay to snap at people occasionally, not all the time. You'll lose your friends, but it's okay to be a bitch. But...

The Patient from Hell (47:09.589)
Thank you.

Fumiko Chino, MD (she/her) (47:23.354)
just realize that we all have good days and bad days. So I give people permission all the time to be mad.

The Patient from Hell (47:31.221)
I don't think I've ever met an oncologist who totally gets patient experience.

Fumiko Chino, MD (she/her) (47:37.802)
Well, I mean, people who've been through treatment, right? And that's it. It totally informs how you deal with people, you know? So, I mean, I haven't been through cancer treatment myself, but I think just, you know, being along for the ride is is bad enough. But I don't know, we're all different. We have different levels of approaching, you know

problems in communication and interpersonal relations and framing things and no one trains us how to be good communicators really, you know, so you kind of got to want it.

Fumiko Chino, MD (she/her) (48:20.382)
It's funny, I feel like sometimes we're shifting the medicine towards, you know, patient centered care and communication, thank God, right? But I wonder if we're not actually accidentally excluding some like really badass surgeons, like they're not even getting into medical school, the person who would be that great neurosurgeon, because we've weeded them out, they're too weird. I wonder, I was like, are we accidentally excluding those people? Because I don't really need that person to like hold my hand.

I just need them to be super like precise and to know exactly what she's doing in the OR, you know. I don't know.

The Patient from Hell (49:01.397)
I think that's a really, really fair point. Actually goes back to our conversation on the experience is everyone and not just your oncologist, right? It's, it's the experience is encompassing all touch points with the system and not just that one appointment. And like I am with you, like actually a mentor of mine actually asked me that he was like, you need to choose because one thing we haven't talked about in this episode, but is I think very true. You have a medical oncologist, you have a radiation oncologist and a surgeon.

And then you may have a primary care doctor. So just as a patient, you're already intercepting at least three, maybe four people, if not all of the other kind of like specialty care stuff. So as a patient, you have many, many people you're touching, right? And at some point you will have a bond with one of them and not a bond with another one of them. But to your point, the surgeon may be a really, really good surgeon and you may just not have gotten to like being buddies with this person. And then how do you grapple with that? And.

One of my mentors actually told me that. He sat me down and he's like, look, you're going to face this. Just remember, they're not there to be a friend. I was like, yes, fair enough.

Fumiko Chino, MD (she/her) (50:11.614)
I feel like we're in a reality show. I'm not here to make friends.

The Patient from Hell (50:15.925)
Oh, yeah, fair enough. Good point. I'm watching the clock and we, of course, have gone way, way, way over. It's not surprising. So as a wrap up, I'm going to go back all the way to art and fashion. Sorry. I don't get to do that. We have to talk oncology all the time. We don't get to talk about art and, you know, it's just much nicer. OK, so if you had to teach all your peers,

Fumiko Chino, MD (she/her) (50:23.134)
Of course.

The Patient from Hell (50:42.517)
not just radiation oncology peers, but like all cancer doctors, anything you could about how they could practice medicine differently by learning something from the arts. What would you tell them?

Fumiko Chino, MD (she/her) (50:58.302)
I saw this in your note preps and I was really, I was like, I gotta have something that really kind of ties together. But I think it's just that everyone, when they look at a piece of art or they see a piece of modern dance or they listen to a song, they're gonna take something different away from it slightly. Even all

Taylor Swift fans are gonna have their own interaction with the song slightly different based on their lived experience and their perspective, so everyone sees something differently, right? And so in that capacity, that communication that you get from, in this case, a piece of art or in between each person, it truly needs to be tailored to that person because someone's capacity for understanding what you're saying

is going to be based on who's in the room with them and what happened to them in the waiting room and their level of education and how much reading they did on the internet before they came in. And it's like if you take a little bit of time you kind of find kind of what they came in the door with, that really helps you get a better conversation with them. And communication is just so vital because it's

really is what builds trust, right? And you said that earlier, which is you just had to trust your, in this case, radiation oncologist's opinion that it was right for you ultimately, because the numbers didn't really make, like they didn't add up for you, right? Right? And so like, trust is communication, right? And communication is, is unique, right? It's like me seeing you, I'm a human being, we're having a conversation.

The Patient from Hell (52:25.781)
Yeah.

Fumiko Chino, MD (she/her) (52:44.122)
I think so many doctors just come to their room and they're like check boxes. Like, okay, we gotta talk about your diagnosis. We gotta talk about the treatment plan. We gotta talk about side effects. Here's the consent to sign. Okay, these were the next steps. And they're not starting kind of from the foundational of like, you know, like coming in the door and, you know, making sure that we're like treating each person as a whole ass human being.

The second thing I would say is that there's no right answer often. Almost always, there's not like a singular right answer, right? And so understanding that, I think all physicians, providers, researchers are like very type A personalities. We want to get the gold star, we want to get 100%, A++. And just realizing that what is the right plan for this person is probably not the right plan for this person. And...

understanding that coming to that conclusion together, trying to figure out again, sussing out, even if it's the small tailored things of like, what can we do to make this easier for you? It's not one size fits all. It's really, or it shouldn't be, how about that? It could be, but it really isn't. Because we're all, as I said, beautiful butterflies filled with white light and...

And each one of our lights is unique. And that's actually very helpful as a provider, again, to like constantly, you know, like we're tested constantly. There is a right answer on tests. There is not a right answer for individuals, right? There's the right answer for them in their situation. But even that can change over time, right? You can have people who are willing to be so aggressive, even in the face of horrible odds. They're...

They're rooting for that 1%, right? And then later on, they're like, that chance of the illusionary cure is not worth it for me anymore. I have too many side effects. I want to go to vacation with my family. I just need a break from this. And that's OK, too, to even have that shifting of what the right answer is. And then the other thing, the last thing I'll say that my perspective, at least from an artist, is that the...

Fumiko Chino, MD (she/her) (55:06.974)
Like that concept of kind of doing what you love, being, you know, in this case, mission driven is the thing that gets you out of bed in the morning, right? And like, if it doesn't get you out of bed in the morning, maybe you should slightly shift your practice so that you can get closer to your true north. And I think that would help reduce burnout, but it would also help make you a better doctor because happier doctors are better communicators. They have better teams and they provide

better care. And this concept of burnout is like so cliche, right? It's like everywhere in the news, yada yada yada. But I cannot tell you how many times when I tell people that I don't work on the weekends that they are impressed.

The Patient from Hell (55:51.615)
I – doc, my thesis was on burnout. This was 2019 before it became front page news everywhere. So I spoke to a lot of clinicians about burnout. And you're totally right. You are an exception if you're not working the weekend. I think that's a great goal for everybody.

Fumiko Chino, MD (she/her) (55:55.068)
Yeah.

Fumiko Chino, MD (she/her) (55:58.94)
Mm -hmm.

Fumiko Chino, MD (she/her) (56:06.462)
Yeah, I don't work on the weekends.

Fumiko Chino, MD (she/her) (56:12.328)
It's really a great I 100 % every single person in medicine we call a weekend where you don't work a "golden weekend," which is just a normal weekend. But this concept that our weekends are golden is like, is tragic, but it's also kind of beautiful, which is like, no, this is golden. Like, this is my golden time. This is like,

gold is like precious, like we need to use it wisely. We need to like, you know, do it up every single weekend. I'm like, what are we doing? Because this is the weekend. I'm still like a teenager in that capacity. I'm like, what are we doing this weekend? It's not even half the time I'm like, I swear I'm like on the couch, like eating ice cream, but like, you know, that's my time to eat ice cream. So, mm -hmm.

The Patient from Hell (57:02.957)
That was, Dr. Chino, this has been amazing. I normally try and synthesize episodes at the very end, but I'm not even gonna try it. That was such a beautiful summary. And I think we're ending on a note that is spend your weekends how you want to spend them, but also eat some ice cream, which seems really good. So.

Fumiko Chino, MD (she/her) (57:21.694)
It's good advice no matter where you are.

The Patient from Hell (57:26.005)
I really appreciate you coming to our podcast.

Fumiko Chino, MD (she/her) (57:28.574)
Thank you for having me.

The Patient from Hell (57:30.005)
This was phenomenal. Thank you.