As a cancer, we know that if you screen early and you catch early, you can save somebody's life, right?

There is no question.

That is why we highly recommend screening when it is age appropriate for you.

But if there are other risk factors that we can identify, we may actually prevent cancer in groups that are at higher risk for any reason.

Foreign hello and welcome once again to the Tridock Podcast.

This is the September 5, 2025 edition and I am your host, Jeff Sankoff, the Tridock, an emergency physician, a multiple Ironman finisher, a triathlete and a triathlon coach.

Coming to you as always from beautiful sunny Denver, Colorado.

We have passed Labor Day.

That means that the very last bastions of what has been a lovely summer are now in the rearview mirror and we can look forward to what is going to be the start of the championship season of triathlon.

We have the Ironman World Championship for the men coming up in Nice in just about a week's time.

We then have the women's World Championship for Ironman coming up in, of course, the big island of Kona about a month after that.

And then just about a month after that, we will have the 70.3 world championship in Marbella, Spain.

And then sometime after that, the T100 final, grand final, whatever that's going to be called.

I believe it's in Qatar.

I will be quite honest, I don't follow the T100 quite as closely as I'm sure a lot of you do.

But I know that that's on the radar as well for many of you.

And that will be the fourth and final of the big championships that are coming.

And I was reminded of how big the Ironman World Championships have been for me as a spectator and a participant when I recently saw an open letter penned by Mark Allen to his great rival and now great friend, Dave Scott.

Dave, who underwent heart surgery last year, actually, it may have been earlier this year and who we haven't really heard from very much as he continues to convalesce and come back from what was a very major surgery.

Mark penned a very emotional, emotional and very honest letter to his great rival and great friend of the iron War from 1989.

If you're not as much of a student of the sport as I and as maybe some others, the Iron War was the event that took place in 1989 when the Ironman World Championship comprised of a bunch of competitors, but really the two at the front all day, from the gun all the way to the finish, were Dave and Mark.

Dave, the six time Ironman winner Mark, who had lost to Dave multiple times up to that point.

They ended up starting the marathon together and ran the entire way, shoulder to shoulder, stride for stride, in what really continues to be looked upon as one of the greatest man on men events, man on man races that has ever happened.

And we got to see the whole thing on television.

It was a remarkable event.

And in the end, Mark Allen took off just as they were climbing the hill before the big drop down into Polani that would bring them into the last mile to the finish.

Mark took off.

Dave could not respond.

And Mark won his first of six of his own Ironman World Championships.

And in his open letter to Dave, he talked about how the greatest rivals push each other to become not defeated, but become even better.

And as I look back on my own triathlon career, I don't have any great rivals, but I definitely have over the years learned how to win based on the many losses that I have had.

And I continue to do so.

And I know that for many of us who are in this sport, be it whether or not we end up on a podium or we just end up finishing, I know that it is losing and it is failing to accomplish what we want to accomplish that keeps us going in this sport.

And so, as we come to the end of another season of triathlon, some of us still have races to go.

I've got two myself.

Many of you may already be done.

We can look back on what were the successes of this year, but we can also think back on what were the things that we didn't quite succeed at.

And it is those things that will really push us to continue to train, to continue to race, and continue to strive to be better.

So whoever your Dave Scott is, whether it's an actual person or whether it's that internal person that you're racing against, don't forget to give them thanks, because they are the one that that are continuing to push you to be better on the show today.

We have a really good one coming up on the Medical Mailbag.

I'm going to be rejoined by Juliette Hockman, fresh off of her vacation across the pond in Switzerland.

Yes, Switzerland.

Yes, that's where she was.

Keep thinking Austria.

But she was in Switzerland.

And she is back to join me on the Medical Mailbag segment when we are going to answer a listener question submitted by the very productive Justin Rayfield, who likes to submit a lot of questions.

And I thank him for that because without him, I think the Medical Mailbag might dry up.

But Justin's got Another good question that's come in.

He's asking about the use of Arnica, another naturally derived product.

He wanted to know if there's any science to support its use.

We are going to take a look at what intern Cosette Rhodes came up with, and we will give you an answer.

And a little bit later on in the show, you will hear from the voice that opened the program.

That voice was Stephanie Van Beber.

Stephanie is a longtime friend of mine.

She's a longtime supporter of the program as a Patreon supporter, and she's been a guest host of the Medical Mailbag when Juliet was away in a previous vacation.

Several quite a while ago, actually.

But Stephanie is back to talk to me about a story that we ripped from the headlines.

We have the first ever Tridock podcast scoop.

Stephanie's going to talk to me about a story that was in the newspapers very recently about a study that she was involved in.

That study looked at ultra runners and the potential increased risk for colon cancer.

She's going to talk to me about how that study came to be, what it found, what it means for all of us and whether or not we need to be concerned.

We're going to have all of those things coming up.

But it begins with a look at Arnica in the Medical Mailbag.

And that is right after this break.

It is that time when I'm joined by my friend and colleague back from vacation across the pond, Juliet Hawkman.

Welcome back.

It's good to see you.

Thank you.

I missed you last time.

Yes, we missed you as well.

We had a admirable in the form of Griffin McMath.

But, Juliet, we are thrilled to have you back in your usual position.

How was your vacation in Switzerland?

I understand there was some great celebrations.

Yes, it was wonderful.

We went with our two adult sons and their girlfriends, and we returned with one son having proposed to his girlfriend, which means we in short order will officially have a new member of the family.

So we are really excited about that.

That's amazing.

Both women are terrific.

And we're, it's just really fun to be over there with all six of us.

So we had a great time.

We're in Switzerland hiking.

Congratulations to everybody.

And then you were there for a wedding, right?

Yes.

And then we ended up going at the end of our time.

The younger generation took off and my husband and I went to Austria for a wedding of an old the daughter of an old friend.

In fact, the daughter, who is 30, was a Babe in arms at our wedding and then was an exchange student.

And stayed with us when she was in high school.

So we've known this kid forever.

And so it's really.

It was a wonderful wedding.

Yeah, it was really cool.

That's terrific.

That's awesome.

Yeah.

Really cool.

It's the best kind of vacation when you have that kind of family bonding and then you get to have that kind of catch up with someone you've known for a long time.

That's really nice.

Yeah.

Yeah, it was great.

Listen to coming back.

So nine time zones, long travel from Europe back to the west coast of the United States.

So it'd be interesting actually, at some point perhaps to have a discussion on what we know about traveling as you get older across time zones.

Because, boy, this time coming back, I just felt.

I just.

Today was my first good workout.

It took a whole week to get to a.

We talked.

We talked not too long ago about melatonin for that purpose.

It's one of the few things that can help a little bit in terms of shifting your clock.

We know that light is also.

And we're gonna be talking about light therapy coming up in one of our next episodes.

I have.

Nina Takeshima is right now looking into a new product.

It's a light mask that is supposed to help with shifting your internal clock.

So we're gonna come back to that question in an episode coming up.

All right, good.

Yeah.

I think as you get older, there's no question it gets harder.

And we know that for every time zone you cross, you need about one day.

So your experience of about a week for nine time zones, about on par.

So that makes me feel a little.

Bit better because I felt like garbage.

I was sleeping fine, but my workouts were garbage.

You know, what I found is when we went to Asia recently, my wife and I, that is a shift of 18 hours.

So it is such that you are.

Because it's 18 hours, it's not.

It's just six.

Six hours.

Yeah.

So it actually doesn't feel nearly as bad as you would think it does.

And coming back was the same thing.

It's much easier.

I find it when you do those huge amounts of time, like flying like halfway around the world.

I find it's when you cross the date line, it is easier.

Yeah.

Yeah.

But yeah, like those shifts across to Europe, I agree with you.

They're tough.

We are going to take on a new subject coming up, but I wanted to do a little bit of follow up on last subject of the medical mailbag, which was creatine, because I've heard from a lot of listeners.

And we didn't really get a chance to talk to you about it.

And I wanted to hear your experience and thoughts as well.

I know you've had a chance to listen to the episode.

What did you think and what thoughts did you have?

I thought the episode was great.

And once again, as you did the first time you reviewed creatine, there wasn't a whole lot of new learning.

It appears, correct me if I'm wrong, that it still doesn't have.

There's no good evidence that shows it is a performance enhancer for endurance athletes.

I liked that your.

Your other.

Your substitute, Juliet, or offered some compelling thoughts about its use for mental acuity.

But once again, it appears it's a supplement that for our corner of the world, triathlon, endurance sports, et cetera.

It really doesn't have any.

There's no evidence out there that suggests that it helps.

So yet another highly touted and oft used supplement that doesn't help.

It is.

It is crazy.

And like I said in the.

At the time when we were recording just how much creatine is pushed and by how many kind of corners.

And I know you have athletes who've asked about it as well.

Yeah, for sure.

You have athletes who use it, right?

Yep.

At LifeSport we have a women's feed and it comes up from time to time on the women's feed.

And a number of women use creatine.

I have an athlete to ask about it.

I myself have never used it.

I don't really use any supplements, but.

And people, I think people get stuck into something and I don't know if there's a placebo effect or there's.

They have an N of one and there's.

They're not really looking at what's causal and what's not.

But people, it's like you have told me a million times in collagen doesn't do anything.

And after this can of collagen, I'm going to throw it out.

I'm going to not order it again.

But it has taken me a while.

To get through it.

Yeah.

The interesting thing about creatine is one of those supplements where you can actually see a change.

And we know that if you take creatine in large enough doses, you are going to get a change in your body and your body type is going to change, you're going to increase muscle mass, you're going to increase water and things like that.

And so you are going to see a physical change.

And so I think that's part of the reason why creatine has been as popular as it is because it's one of the few things that you can take where you can have this visual feedback.

Yeah.

And I actually had one listener make a comment in the Facebook group where Dan is his name.

Dan mentioned that as he ages, he continues to use creatine because he believes and feels like it's helping him maintain his muscle mass, which is something that we all struggle with as we get older.

I didn't find any evidence that talked specifically about that intent, but I certainly it tracks with what we understand about creatine, so that that kind of makes sense.

And I had other listeners reach out and say another person commented in the Facebook group about how she and admittedly she said, look, this is my n of one experience, but I've had great success using creatine with it helping my adhd.

And I found no evidence to support that.

But that doesn't mean it doesn't work for her, I think.

And I think it's wonderful that it does work for her.

And as I have said many times on this program, when I present the science on a particular subject, I am not presenting the truth for you as an individual.

I am producing the truth for populations that has been synthesized in these research studies and that will generally cover most people.

But there are going to be outliers.

There are going to be people who have different experiences, and I can't predict that.

And I certainly am not going to tell anybody that their experiences aren't real, because I can't do that.

So if you have had a benefit from using a certain thing that I have said is not doesn't have evidence to support it, that doesn't mean you should stop getting your benefit.

And if you feel like creatine is giving you a benefit, then by all means continue using it.

I'm.

I don't be dissuaded by the evidence, but as I said at the time, and I'll continue to say, if you're taking creatine believing that you're going to get some kind of bonus or some kind of enhancement, as you said, for endurance sport, that is simply not likely to happen based on all of the.

And it's a large amount of evidence that we've seen at this point.

So I think it's like anything don't.

Marketing is very powerful.

Social media marketing in particular, when a person who is known is espousing its value, et cetera, is very compelling.

Oh, this triathlete or that runner uses it.

I should too.

And even our Friends who we trust, there's that sort of escalation of commitment or what's it called, user bias or something.

There's an expression for it, right?

Oh, no, Jeff, really?

Eating chocolate before every workout, that's the way to go.

Every workout that I eat chocolate for, that's the way to go.

It's good work for you too.

Like, I have my own bias, confirmation bias, that's what it is.

And, and even your well meaning best friends, they may have an end of one experience which isn't going to work for you.

So you just have to go into.

These things with your eyes wide open.

Yeah, yeah.

And take all of the different sort of evidence that you're hearing and make your own decisions and then you can experiment with some of these things and see what happens for you and then make an educated decision that way.

But it is hard when you have a thought going into it that, oh, this is going to help, and it's hard to see that it doesn't.

But anyways, I thought it was a worthwhile subject.

It seemed to engender a lot of conversation.

I had one other person reach out who wanted me to clarify.

I have used lactate as I talk a lot about lactate and about anaerobic threshold and about how it produces lactic acid.

And this particular listener was taking me to task rightly, that I am simplifying the biochemistry there.

And lactate is not really a terrible thing.

Lactate is just a byproduct of metabolism.

It is actually a fuel that can be used by our cells in anaerobic metabolism.

And what his point was is that creatine, and specifically phosphocreatine, really neutralizes intracellular acidosis, which is the hydrogen ions that are liberated at the same time.

And it's intracellular acidosis that interferes with our ability to do work.

So he wanted me to be a little more, I think, accurate in my science.

And when I talked about these things and I said, at the time, I said, I have to be careful.

Not all the listeners are going to understand.

Everybody understands lactate.

I'm not sure everybody will understand intracellular acidosis.

But he, he was 100% right in calling me out on that.

So I do want to recognize that and make amends and just say, when I refer to lactate, what I'm really referring to is this idea that we are developing an imbalance of acid base chemistry within our cells and overabundance of hydrogen ions, which can lead to problems.

Anyways, all right, we'll leave it at that, we're gonna take on.

We're gonna take on a new subject for this particular episode of the Medical Mailbag.

And it's a question coming from our good friend Justin, who is a frequent contributor and.

Thank you, Justin.

Without you, we would have half as many questions.

Exactly.

The curious mind.

Justin has a curious mind.

Exactly.

Yep.

So Justin wants to know about the use of arnica, which is a homeopathic remedy used topically because it's, as you pointed out, it's highly poisonous if you take it orally, but it's used topically and it's supposed to address inflammation, amongst other things.

You said it was a derivation of the daisy?

Yeah, the daisy.

Yeah, it's derived from the plant in the daisy family.

Daisy family.

Okay.

Yeah.

So what did your people find out about arnica?

And is this something that we should be slathering over our bodies for recovery purposes?

So the intern for this was Cosette Rhodes.

So thank you, Cosette, for doing the research today.

And she found a fair number of studies that looked at the use of arnica in athletes.

I actually thought arnica was a supplement.

When Justin proposed this to me, I just assumed because it was plant derived, like so many of the other plant derived subjects or plant derived substances we've talked about, I thought, oh, arnica must be another supplement.

And so I said to Cosette, I said, could you look into arnica supplements?

And she looked it up and the first thing she came across is, do not take this stuff orally because it is highly poisonous.

So it's also known as wolf's bane.

That's right.

Wolfsbane is its.

Is its kind of, I guess, colloquial name.

Yeah, correct.

But it was originally used by the Native Americans, Native Canadians, indigenous peoples of North America, as a kind of medicine, I gather.

I'm not sure exactly what its uses were, but not taken orally because I'm sure they learned the hard way that if they did didn't fix anything and actually led to significant illness.

It.

It does not have to be taken in large amounts to be quite toxic to both the kidney in the liver, but it can be applied topically.

And the theory goes that using it topically is a way to avoid chemical anti inflammatories and get a bio kind of friendly anti inflammatory.

And the studies that we found were all looking at whether or not arnica applied topically in a cream or some kind of ointment worked to reduce the amount of pain and damage in muscle that we see after doing these really hard workouts.

Often these were lifting weights.

Sometimes it was doing really hard interval workouts.

But it was basically all the same thing.

We found four different studies and all of them looked at the same thing and we could just go through them because they're pretty quick.

The first one was, and I should also mention, arnica is heavily used in the homeopathic.

I don't want to call it medicine, Homeopathic industry.

I don't know.

Homeopathic, it looks like it's used a lot for osteoarthritis.

It's used a lot to try and alleviate the symptoms of osteoarthritis.

Yeah, we didn't look at that because that wasn't really pertinent for our listeners.

But so homeopathy is a branch of healing.

I don't even know what to call it.

But basically it's alternative.

It's considered alternative medicine.

Alternative medicine.

I was looking for that.

Alternative medicine.

Basically there's a couple of principles.

I don't remember what it's all what they're called, but one of them is if you put a very tiny amount in a large solution that all of the molecules in the solution will learn the properties and take on the properties of what you put in there.

So if you put a tiny amount of arnica in a large amount of water, all of the water will behave like the arnica.

That's one of the tenets of homeopathy.

And so you will probably get a sense of what I think about homeopathy.

Okay.

But homeopathic medicine is different from naturopathic medicine.

They are different.

Yeah.

Okay.

So let's just make sure we.

They are different.

Yeah.

I can tell you right off the top of my head what the differences are.

But they are different.

They're both alternative.

Okay.

Effects of the homeopathic remedy.

And anyways, arnica has got a big, big following in the homeopathy world.

So.

Effects of the homeopathic remedy arnica on attenuating symptoms of exercise induced muscle soreness.

This was in the Journal of Chiropractic Medicine.

I will say that if you were ever going to find a positive study for arnica, I would think it would be in the Journal of Chiropractic Medicine.

They looked at 20 athletes who were doing exercises only with the arms, weightlifting, like really intense weightlifting with the arms to induce delayed onset muscle soreness.

It was a very well designed study, randomized, double blind.

And they looked at objective measures of soreness as well as subjective metrics and compared it to placebo.

Really good Study and basically found that after these 96 hours, Arnica showed no significant effect compared to placebo in reducing muscle soreness, improving muscle function or limiting any of the biochemical markers that they looked at for muscle damage.

So negative study, this one from 2005.

More recent study in 2014, the effects of topical arnica on performance, pain and muscle damage after intense eccentric exercise.

This was the European Journal of Sports Science.

They had people doing downhill running.

Oh my God, how?

Yeah, we were in Salt Lake City this weekend and I did a half marathon at Salt Lake City about a year and a half ago and I got to show Adam the hill that we ran down, like this three mile hill, that was just a ridiculous amount of elevation.

And I could not walk for the next week.

I was in so much discomfort in my quads, it's awful.

So this study really resonated with me because if arnica worked for this, I'd be like, okay, I'll go back and do it again.

So the effects of topical arnica on performance in this kind of exercise.

Downhill running protocol 20 well trained male only double blind study looked at pain, soreness and performance in arnica to placebo after five, four or five days and basically no effects.

So arnica again, not able to do anything.

And then third study, this one was particularly interesting because of its findings, but this is the annals of pharmacotherapy.

The effect of topical arnica on muscle pain doms induced via calf raises.

So they induced delayed onset muscle soreness by having people doing very intense calf raises.

Ouch.

Ouch.

And what they did was again a very good study.

These are all really good randomized double blind Designs with fairly 53 athletes.

In this one looked at pain post exercise 24 hours, 48 hours, 72 hours.

They actually found the group with arnica had higher amounts of pain at 24 hours.

But then there was no difference at 48 and 72.

So probably not going to want to take arnica when you're downhill run or doing calf raises.

And then at the last one, mud pack with menthol and arnica.

Arnica Montana specifically this one says accelerates recovery.

So you're already getting a bit of an answer for what they found.

Mud pack with menthol and arnica Montana accelerates recovery following a high volume resistance training session for lower body in trained men.

Now arnica is supposed to or purportedly has some anti inflammatory properties, whereas menthol is an agent that increases blood flow so it vasodilates locally.

And you could see how those two things might work together.

But the big thing is that you could see how menthol might actually contaminate the results of the study.

Because improving blood flow to an area that's painful, washing out some of those evil humors and helping restore oxygen flow, oxygen delivery and repair to those tissues also might do something so DOMS induced by high volume lower body workout 10 well trained males, randomized crossover design comparing pain and soreness and Arnica administered via a mud pack containing menthol and Arnica Montana to placebo.

After four applications, the arnica group described decreased muscle pain and had a faster recovery of isokinetic strength at slow speed.

But again, I'm not sure.

Was this the arnica?

Was this the menthol?

Was it both?

Was it the combination that did it?

Not entirely sure what to make of this one study when all the other studies were clearly negative.

But for what it's worth, want to always include all the evidence we find and we did find one study that did show that arnica had a small benefit.

That's what I got.

It's really not a huge amount of evidence because we couldn't find a whole lot, but I did think that it was enough to say that probably not going to be using Arnica personally.

If anybody out there is finding Arnica helps them, please let me, let us know.

Love to hear individual experiences because I think they're important.

But based on this evidence, I think that.

Justin.

Sorry, pal.

Yeah, yeah.

Another one could skip.

Yeah.

Juliet, I know that we were chatting a little bit about the Marbella course.

What are your thoughts?

You've been talking about this quite a bit on your various podcasts with you and that and tempo talks and obviously you've been a valuable contributor to the LifeSport coaches feed on this particular topic because you're going to race and so you need to think of that.

You're giving it a lot of thought.

Yeah, give it a thought.

I know.

No, it's really great.

No, I actually, I have two athletes going.

I know you're racing.

You probably have an athlete or two going as well.

For those of you who have been living under a rock for the last two weeks, what Jeff is talking about is that the World Championship 70.3 World Championship Bike course was finally revealed after much delay and it proves to be quite a doozy with 5,800ft of climbing over 46 miles.

And remember, it is a 56 mile course.

Or is it 42 miles?

Anyway, a lot of climbing.

There has been much buzz across all of the channels in terms of 1 TT bike vs road bike 2 what type of gear ratio people should be striving for and also just what coaches should be recommending for their athletes and how to help athletes make decisions about this.

I think you hit the nail right on the head when you talked about.

Before you can even have the discussion of TT bike versus road bike, you need to really talk to the athlete or consider the athlete's prowess and confidence on the bike, both in terms of climbing and in terms of descending.

Are they very confident?

Are they able climbers?

Are they able descenders?

Descending on a TT bike is trickier than descending on a road bike for sure.

And then once you had that conversation and you've determined road bike or TT bike, then you start thinking about gear ratios and what to have on that rear cassette.

I know that you're switching from a one by to a two by.

I think that's pretty smart.

But yeah, no, this has been a hot topic of discussion.

Of course I, I've elected not to go this year.

But I have been thinking, I wonder what I would have done.

And that's what I wanted to ask you.

I wondered if you might be looking at this course going, oh, this would have been a good one.

I do love to climb.

I am a good climber, I am a good descender and it would have been a great course to do.

However, as I explained to my brother when I was chatting with him the other day because he was asking about whether I was going or not, I actually would, I would have probably have to get an entirely new TT bike for this because my TT bike is very old.

I run 23s, I run tubulars, I.

Have a 10 speed.

It is absolutely.

They're not disc brakes.

Even as good a rider as I am, I would probably not take on this course on that bike.

It just wouldn't.

I wouldn't be able to ride it aggressively, which is what you want to be able to do.

I do want to touch on that just for a second because I have heard a little bit about that think that disc brakes are the end all to be all and that rim brakes are just not capable.

I want to remind people that it's only been 10 years.

The tour de France, the Vuelta, the Giro.

These are guys who were and women who when they have ridden would ride rim brakes forever in all kinds of conditions.

And I'm not suggesting, I think I named like 10 factors and that is only one of them.

I would ride this course on rim brakes.

That would be fine.

And I think that a lot of Athletes will.

And as long as you know how to brake correctly and using rim brakes.

There are people who ride gravel races on rim brakes and that's way crazier.

But I don't think it's huge, Juliet.

I think it's a widespread kind of feeling that people have because we've become so used to seeing disc brakes everywhere.

And look, let's face it, we all know because of hydraulic disc brakes specifically, it's just very easy to get good stopping power with minimal force applied to the brakes.

I'm taking my bike with rim brakes and I'm okay with it.

I did it in Nice and it was fine and I rode like a nervous person in Nice and so I was on those brakes a lot of the ride.

And I don't know what the Marbella descent is, but if push comes to shove, I'll be on those brakes again.

And I'm confident using those rim brakes.

And so I don't, I don't want people who might be listening to this thinking, oh, the better bike that I have for climbing has rim brakes.

And therefore I don't want to take it because I might be thinking that, yeah, they shouldn't, because they shouldn't think so.

Very capable.

Yeah, no, absolutely.

Both my TT bike and my road bike have rim brakes and I ride in a place that is just all hills all day.

And it's more about your confidence and your skill descending, particularly around corners, than it is about which type of break you have.

So I wouldn't call that a single limiter at all.

I, I did a big ride this weekend out in Utah.

People warned me not to do what I did and my son, the, the gamer was, oh, come on, we gotta do that.

And of course he was fine.

The old man had a little trouble, but it was an epic day and it made me realize that gearing is so important.

Not.

This was a ridiculous.

This was 7 plus miles at double digit percent.

It was real.

It was the hardest climb I've ever done.

So were you standing and postmanning it a lot?

I didn't have to postman it, but I was stand.

I felt like I was practicing my track stand quite a bit and it was by far the hardest climb I've ever done.

It was just brutal and it made me realize again, like, I just got this cassette for the bike and I'm hoping it's somebody like Brian pointed out in one of the Facebook groups.

He said, are you sure you don't want to get an 1132?

Because I got an 1130 or maybe I did get, I think he said 1134 or something like that.

And I'm like gosh, I hope not.

But anyways, we're going to find out.

I think it'll be fine.

Yeah, you're a strong climber.

It is interesting though.

It does.

We both know we have a mutual friend who had an athlete the minute he saw or I don't know if actually the athlete is male or female the minute this athlete saw the course they bailed on going and which I think it just breaks my heart when I hear that.

And I was reminded I ran a Clinic yesterday for 70.3 Washington which is coming up in three weeks.

And you and I will both be there.

And as you remember there is at about Mach 15 there's about a two mile climb which is quite steep.

And everyone always loves to freak out about this particular climb.

And I took five athletes or six athletes up that hill yesterday.

And it is a reminder to me that our athletes, many athletes out there can practice climbing more just watching the way athletes climb.

Some athletes don't know how to stand when they climb.

Some athletes don't understand how to approach, anticipating, gearing as the hill undulates a little bit so they're going way, way too fast and they're just cranking.

Some athletes gets so tense and you can just see so much energy going into all the wrong places across their entire body.

Yeah.

And I know that not everybody has the luxury of being able to ride outside a lot but we can practice these things on the trainer in the winter.

We can practice.

I just, I, I like unless you were always going to ride in Texas and Florida, one of the best things you can do for yourself is to learn how to climb.

Though I do sympathize with people who do live in places where they can't get good long climbs.

And you can us usually find a hill that you can climb for a couple of minutes or so.

But we need, we're talking about like that two mile climb in Washington is the perfect one to practice on.

And obviously I have climbs here in Colorado and you have climbs where you are which are perfect but it's tough.

Like you could do some things on the trainer, you could do something with over gear training.

But there is just something about the having the bike on a gradient and knowing how to shift your weight and those things can't be practiced on the flat.

So I do sympathize.

I think you could work to build your strength.

You could work to practice things like standing in the pedals but there are other things that until you actually get on a hill, it's really tough.

It's tough.

And I do definitely feel for people who don't have access to the kinds of climbing that we do here and that you do where you are.

A hundred percent.

I agree.

And I think there's a lot of athletes out there who just don't.

Who live actually in places where there are.

Yeah, they just won't go out or they just.

I don't like hill.

I don't like hills.

I don't want to go up hills.

And I'm like, there's all these hills.

Right.

Where to speak to that woman that just dropped out.

Look, I think a lot of people go to Worlds because they want to compete.

A lot of people go to Worlds because they want to enjoy the experience.

And I can imagine somebody looking at that course and going, I am not going to enjoy that.

I may not even finish it.

And therefore thinking, why am I going to go all that way?

So I can understand that.

And it's one of the reasons why I think it's honest unfair for Ironman to drop this course as late as they did.

It was really late this year.

Yeah, it was really late.

Yeah.

The qualification period for Worlds is a full year, and so I don't expect them to have it out the moment qualification opens.

But, yeah, this is really.

Yeah, all right.

But for you, you're a good climber and a good descender, so it'll be.

It'll be fun to watch you go.

No, I'm looking forward to it.

I think it's.

It's definitely going to be fun.

And I. I do like to climb.

Look, I worry more about what it's going to feel like to run off of that.

Honestly, that's the hard part.

Running in Nice was because it wasn't as much, but this is going to be a lot.

So we'll see.

We'll see.

I'm going to.

But.

Yeah, but everyone's in the same.

Everyone's in the same boat.

Everyone's got to run.

Yeah.

Exciting.

Julia, thanks as always, for being here with me.

It's great to have you back.

I look forward.

We are, what I am like, 17 days away from seeing you in Richland, so I'm excited about that.

I rode by our.

Our condo that we got last year that we're doing again this year, which is right there, and I just.

So good.

Yep.

That's great.

I will talk to you, of course, before that.

One more time, for one more episode.

And until Then thanks for being here.

Thank you, everyone, for listening.

If you have a question, don't forget to send it to us.

You know how email, Facebook, group, you can do it all kinds of different ways.

We'd love to hear from you.

Juliet, thanks for being here.

We look forward to seeing you on the next episode of the Medical Mailbag.

Thanks so much, Chef.

I am particularly excited about my guest on the podcast today for a number of reasons.

Number one, she's a dear friend, someone who has been on the program before.

She has been a longtime supporter of the podcast, both as a listener and as a Patreon supporter.

So I'm thrilled to have her for all of those reasons.

But this is also the first scoop that the Tradoc podcast has had going behind the headlines.

A story ripped from the front page of the New York Times.

And to join me to talk about that story is my friend, Stephanie Van Beber.

Stephanie, welcome to tritarch Podcast once again.

Enjoy.

I want to get really into this right away because I know that all of my listeners have heard this.

I was surprised to see that you were linked to the story.

It came out on your Instagram feed.

And so I immediately reached out and wanted to get you on the program.

And so this is a scoop.

You have not appeared, as far as I know, on any media channels until now.

I came to you first.

We are going to get deep into this.

All right, so the headline that I know that many of you, if not all of you, unless you were under a rock for the last couple of weeks, have probably seen, because it was really, it went viral.

And basically it was in the New York Times first it said, are marathons and extreme running linked to colon cancer?

And this was a headline that came out when a study, a preliminary study came out that had this finding that runners, particularly those who run marathons and ultras, had an observation and we're going to talk about, really, we're going to get into the weeds of how research is done in just a little bit.

But there was an observation in a cohort of runners that they had a higher incidence of precancerous adenomatous findings on colonoscopy.

We're going to get into what all of that means.

But first, Stephanie, tell us what your connection to this study was.

Tell us who you are, what you do for a living when you're not swimming, biking, and running and coaching, and tell us how you were involved with this study.

Thanks, Jeff.

Okay, so when I am not swimming, biking and running, I have the great privilege to Be the senior director of a clinical research office at the Inova Schar Cancer center in Northern Virginia, which is part of the Inova Health System.

So what does that mean I do?

It means I run a program that implements clinical research, often like the clinical research studies that you talk about.

The same model as to doing a lot of randomized control trials, but exclusively in the area of oncology.

So we are exclusively looking at any kind of study that might touch or potentially prevent or screen for or diagnose cancer.

All of the studies at our center are run by the team that I work with and sometimes those studies are designed and done by the physicians that I work with directly so they come up with the idea.

We design studies, we implement it in, I'll call it real world practice where we have sometimes hypothesis testing, sometimes feasibility testing, and sometimes true randomized control trials that we run that we have designed and come up with ourselves.

And what is your training?

Stephanie?

I know you're not a medical doctor, so what is your training?

I am not a medical doctor, so I'm going to defer.

I'm already saying this in advance.

Anything that has medical doctor terminology, I'm deferring to you.

Even though I am involved in the study.

I am a health economist by training and found myself in my early career doing a number of studies in primary research using kind of tools of a health economist and really actually started in the cancer screening realm in my early days.

So I've come to full circle.

I've come back to the cancer screening realm through this study, but really just ended up being an operations person running programs, looking at overall sort of big picture.

How do you fund these things?

How do you get people in place to do these things?

How do we talk about clinical research in such a way that it removes some of the mythology so that we can get people to participate?

So I do a lot of public facing, talking to patients about what it means to be on a clinical trial and trying to help folks to understand when they are on a trial what that means.

All right, now let's begin first and foremost with what the study's overarching findings were.

I know you're familiar with them.

And then we will talk about how the study came to be and what its design was and why we should be a little bit cautious with the headline screaming about what it was saying.

So what were the overarching findings of this study?

So the big finding that was probably the headline worthy finding was that of the hundred people who we had volunteer to get a colonoscopy 15 of them had advanced adenomas found on colonoscopy.

And the reason that is significant is that was a much higher number than would have been expected in the historical control that we picked as the comparison group.

And it was a specifying test too.

If you took 100 people, age matched controls, you would expect to find how many with advanced adenomas?

1.2.

Based on the historical data that we were looking at.

In your group, 100 runners.

And in your group of 100 runners and ultra runners, it was 15.

So a very dramatic increase, very dramatic.

The interpretation was that, oh, there's something about running and ultra running that may have been conducive to the formation of these adenomas.

Now, I want to just clarify.

An adenoma is a precancerous lesion.

It's not colon cancer.

Correct.

But it is the reason why we tell people to get screening colonoscopy, because if you find an adenoma, it should be removed before it has a chance to become a cancer.

But the presence of these adenomas in people who are under the age of 50, a lot of them were under the age of 50, is a surprising finding.

So how did the study come to be done?

So this is the really interesting part about how we got here.

This physician who led this study, Dr. Timothy Cannon, had.

Okay, so let me back up.

We have been seeing we as in the global we, not we at my site, for some reason, yet to be understood, that younger people below.

And when I say younger people, what I really mean is ages less than is the recommended colorectal cancer screening age.

So when we recommend screening for people, the reason that we recommend is because there's some level of evidence that there's a risk level that we want to try and get that screening in place.

And age is a factor.

So currently, the age at which one would normally get colonoscopy can be as early as 45, but most people target it at 50.

So what is being seen in the last, I'm not even sure how long, but let's say decades, is that there's been a rising rate of young people getting colorectal cancer.

And there's lack of clarity as to why that is.

As this physician, who is a specialist in GI cancers, cancer, the gastrointestinal system of which colorectal cancer is one.

He's had three patients in the span of about a year, all young, all under 45 years old, two of them in their late 30s, and they came to him with late stage colorectal cancers upon Diagnosis.

And he.

The commonality of these three, who otherwise had no significant risk factors of the ones that we would look at for colorectal cancer, often being diet, age, gender, tobacco use, alcohol use, are some of the ones that might be at top of your mind.

They did not have this.

What the three of them had in common was they were both.

They were all ultra distance runners.

Okay.

And so he thought, wow, this is curiously interesting to me.

I don't know, but there's like a biological rationale that one might be putting themselves at greater risk through this extreme running.

And again, you probably can explain the biological rationale better than me.

If you want to do that, I'm very happy to hand it off to you to explain it.

But basically he anecdotally said, I wonder if there's something there.

Let's think about that.

The other thing that was happening, and this is again, this is like real world stuff that happens is the two of two of the gentlemen died and their wives were very interested in how they could help with a legacy of what can we do in cancer?

What can we do?

And these men were defined by their ultra running like they were not.

They were well known in their community.

And it came together as he thought, what I wonder if we can do a study just to see like totally hypothesis testing.

Let's just see if there is something there that's worthwhile pursuing.

And I think again, the other thing I would stress is, yes, this is for extreme running, but there are other ways that you could imagine that you could hypothesize that it might not just be extreme running that is impacted by the potential biological impact of, of what we were looking at.

Again, it's coming back to colorectal cancer in particular is a cancer.

We know that if you screen early and you catch early, you can save somebody's life.

Right?

There is no question.

That is why we highly recommend screening when it is age appropriate for you.

But if there are other risk factors that we can identify, we may actually prevent cancer in groups that are at higher risk for any reason.

This just happens to be one thing.

It may be as likely that somebody is an ultramarathon runner putting themselves at higher risk as having a genetic mutation that's very rare but still puts you at higher risk.

So, yes, very small in terms of like how many people out there are running ultramarathoners or ultra marathoners, Tiny population in the world.

Right, we know that.

But it is worthwhile pursuing because we can't screen everybody.

So the better we can define Risk, the better we know who to target when it comes to helping prevent cancers down the road.

Right now you said a lot.

I want to try to unpack some of the things that you said for the listeners who might not have picked it all up, because I think a lot of what you said is super important.

Important.

Number one, most important, colorectal cancer, highly lethal if it's discovered late, very curable if it's discovered early.

And that's why screening's so important for everybody.

The recommendation is once you hit 50, if you have a family history, if you have other kinds of risk factors, juvenile polyposis, other kinds of diseases that are chronic, those are all well known and associated with early onset cancer, and therefore you should get screening early.

You will know if you're in that group.

But for most people, the Recommendations currently are 50 and up should all get screening, and it is usually repeated every 10 years thereafter, because if you have a clean colonoscopy, you generally don't need to have it again for 10 years.

Okay, that's number one.

Number two, yes, there has been for about 10 to 15 years now a rising incidence or a rising appearance of cancers of the colon in young people.

We do not understand why.

We assume it's probably diet and environmental, but nobody has yet determined exactly what the link is.

Number three, this is often how research comes to pass.

A physician or a scientist will make an observation and will come upon a question exactly like we saw in this case.

A physician noticed three young men who had this cancer, which is very unusual, and then made the observation that all three of them are ultra runners, and wanted to find out, explore that, and said, let's look at ultra runners a little more broadly and let's determine if indeed this might be a risk factor.

And so they did what's called a cohort study.

And a cohort study is very different than the randomized control studies that we have talked about when we talk about supplements or gear or things like that.

So a cohort study is where you start with 100 people who all share the same characteristic.

In this case, they're ultra runners.

And I want to be clear, these were not marathon runners.

These were ultra runners.

All of them?

No.

So the vast majority were ultra runners, or we also included people who self reported they had done more than five marathons.

Okay, so there, there was a mix, a smattering, a sprinkling of marathon runners as well.

Yes.

So then what they did is they just said, look, we want these high volume runners, we're just going to look at 100 of them.

We're not going to really randomize or anything like that.

We're not going to follow them for a long period of time.

We're just going to take a snapshot picture.

Right now we're going to do col colonoscopies on all hundred.

We're going to compare them to historical controls of another hundred and just compare them and see what the numbers are.

And that's what they did.

And they found this alarming number.

Now, we talked, you mentioned that there's this biologic premise.

The biologic premise that's been bandied about here has to do with the fact that when you ultra run and when you do any kind of exertion, even triathlon, but certainly ultra running for a long period of time, you're diverting blood flow away from your gut and you end up doing two things.

Number one, you cause inflammation within the gut lining.

And that is, we know chronic inflammation can be deleterious.

And so if you have localized chronic inflammation in the lining of the gut that may be promoting mutations in the genetics that may be promoting the formation of these adenomas.

The second thing is that you have a leaky gut, which means that you may be allowing for translocation of the bacteria that live within the the colon.

They may be getting into the walls of the colon and then causing some kind of havoc there.

Again, we don't know exactly.

These are all hypotheses that need to be explored.

And then the third thing is there's something about the diet that ultra runners are taking.

Are they taking in potatoes?

Is there something in the potatoes they're eating when they're on the course?

Is there something about the gels they're using or the nutrition they're taking in large quantities as they go on these 20, 24 hour runs that is somehow causing problems within the colon over time?

All of these are things that have yet to be answered.

We also don't know if there's a threshold.

Are you running 50ks?

Are you running 100ks?

Are you running regular marathons at a certain amount?

Like we don't know any of those answers because the study was too small.

It wasn't able to really tease those kinds of things out.

And so further studies will need to be done.

And that's why it's exceptionally important that you don't take this headline and immediately run away from it and say, oh my gosh, running causes colon cancer.

Because that you cannot.

The only way to know that would be to take 10,000 people randomize 5,000 of them to running and 5,000 of them to not running, and then follow them for an indefinite amount of time and see whether or not the cancer rates vary between.

Between the two groups.

You're not going to be able to do that.

This study will be followed up with a much larger study, which will likely look at runners who run different amounts of volume.

They will get colonoscopies, and they'll see whether or not this teases out in another way, which will be super interesting and will probably give us some better answers about the risk of running and its association with colon cancer.

But it's not necessarily going to give us the answer as to why, which is really what the most interesting piece is.

But like you said, it could inform screening, which is huge, which would be very valuable to know.

Yeah, yeah, very valuable.

So what did the authors and what did the team take away from this and what was their kind of thought about the whole findings of the study?

So I think the biggest takeaway from the scientific perspective is I think the authors would 100% agree with everything you just said.

First of all, there is no conclusion to be made as to whether ultra running leads to colorectal cancer.

But I think that the fact that this suggests a larger study is warranted and worth investing in is probably our biggest takeaway.

Right.

It is worthwhile for us to continue to pursue this link in a more robust way.

And so we will very likely be doing that.

We've had an extraordinary response, frankly, from around the world, not only because of the headline, but also because apparently we're not the only ones considering this.

Right.

So there are other scientists out there looking at this, and there are other things being suggested to our team right now as to how we might collaborate and look at some more specific biological factors that might be related to this finding.

So that's the number one, and I think the number two thing that I would say from my reading of it and from the results that I found is that the one significant difference between the folks who had these advanced adenoma versus the folks who did not have, and I should be clear, adenomas were actually found in 41 of the participants.

But advanced adenomas, meaning there was a significant size or a significant characteristic about the adenoma itself, was just the 15.

Okay, so of the advanced adenomas, one of the significant differences found was that all of that, there was a significant, significantly higher number with advanced adenomas who reported basically blood in their stool.

And so I think the takeaway for me to the running community is that this is not normal.

Right.

If you.

There was a.

So we talked to some of the participants and the thing that we heard was, yeah, we know, I know I had blood in mind, stool.

But we were just told that was normal for a runner.

And so I think it was.

That was a finding.

And so to me, the other thing here is sending the message like that's actually not normal.

And maybe something you should go to a doctor to ask about if that is happening to you.

Even if it's happening a lot in the running community, which there is.

There are other studies, not ours to suggest it actually does happen a lot in the running community, that even single marathons.

But it is maybe a symptom that is worth asking a physician.

It does not mean you have colorectal cancer.

It does not mean you will even have advanced adenomas.

But it is maybe something that we should pay attention to as endurance athletes.

Yeah, the bleeding.

The bleeding is from basically ischemic colitis.

So what's happening is, as I mentioned before, you're doing these long endurance events.

You become dehydrated, you divert blood flow away from the gut.

The gut is exquisitely sensitive to oxygen and lack of it.

And when you suddenly divert blood flow away, there's a hypoxia of the lining of the gut.

It becomes leaky and blood can.

Now it starts to bleed, essentially.

So you get some colitis and you can have some bleeding.

And I would never say that's normal.

I would always say that is a reflection of deranged physiology because of inadequate hydration and because of inadequate planning.

Really, if you're doing an ultra, you shouldn't be having colitis unless you're really not doing things right.

And I would 100% agree with you.

If you're having bleeding in your stool, that should be a sign to go get checked out.

And it's just.

That's just.

And I can completely see and understand how that would have become normalized over time, but that needs to stop.

And we need to encourage people to.

To not normalize that any longer.

Absolutely.

And I should note that bleeding in.

If you.

It is known that exercise can result in some blood in the urine.

And I've talked about rhabdomyolysis before.

I've talked about heat induced.

The rhabdomyolysis.

And you can have a pink tinge to your urine and that can be not normal.

It should never be just accepted.

But if you pee once and there's a little bit of pink, that's sometimes okay.

But really, Anytime you see blood somewhere it's not supposed to be, it's probably a good reason to go get things checked.

Yeah.

And so that.

Sorry, Stephanie.

No, I was going to say, not that I'm wanting to point out flaws in our study, but one of the things that you point out several times when you do your evidence based reviews is the idea of bias.

And the reason that the randomized control trial is so good is it does the that it is the best design we have to eliminate bias.

So one of the possibilities that happen in our study is that we may have a biased sample.

We may have a sample of people who were already worried that something was not right and they came to us because.

Selection bias.

Yes, a selection bias because you can't get a colonoscopy if you're 35 and your insurance will not cover it.

So bear in mind that there is entirely that leads us to ask the question if you have too much selection bias, is that mean our results are not real?

So we don't know.

And I just want to clarify.

So the way you recruited patients was you just advertised locally.

Are you an ultra runner?

Would you like to get a colonoscopy kind of thing?

Yeah, no, we went to marathons, we went to trail running communities locally and advertised.

We had flyers.

I mean it was completely self deflected.

Yeah.

So the potential for that bias is definitely there.

But again that's why it's so important to be careful about how you interpret these preliminary findings and these preliminary studies.

And it's unfortunate that finding is going to linger because the follow up study won't come out for potentially years and that preliminary finding on the headline is gonna sit there and if the follow up study finds that.

Oh actually no, that was a selection thing.

And when we did our follow up much larger study, there was no connection.

That probably won't get as much press.

And so instead you're gonna be left with this which is.

Let's flip it to more positive.

Yeah, let's flip it to more positive though instead of discouraging running, let's hope this encourages screening.

Right, so you're a 45 year old ultra runner right now, sitting, listening to this.

You get yourself screened in five years or earlier.

Some insurances will cover screening Starting at 45.

So find out what your insurance covers.

If you have health insurance, hopefully you do.

And that can start at as early as 45 for regular guidelines.

So that's my hope.

I cannot think of better advice.

That is a fantastic.

So Stephanie, I know that you've been dealing with a hip problem.

It's taken you out of your beloved sport of triathlon this year.

You've switched over to Aquabike and you've had a very successful season.

Thank you.

You continue to coach.

Tell us a little bit about your coaching business.

Yes, I have a coaching business.

It's called SVB Coaching.

You can find me online.

Although personal connections is typically the way that I find most of my athletes.

I coach mostly multi sport athletes but some pure runners.

Very excited.

I was out training with one of my athletes doing Ironman Maryland in a couple weeks time.

I was out riding the course with him this past weekend.

Good to get out.

I know.

Jeff, you and I have talked many times about how one to one coaching as human beings is so much more satisfying.

I just by spent two days with one of my athletes.

I spent another day in the pool with another athlete this weekend.

It's just that is my very favorite part of doing this.

I think if it went away I just wouldn't coach seeing their progression.

Being able to see somebody physically on a bike.

But more importantly we don't get paid to do well.

We don't get paid to be athletes most of us.

And it's really just a joy to see people in person and listen to what's going on in their life and being able to incorporate that.

That's to me the best part.

It's like when somebody tells you I had, we had a long weekend here in the US and in Canada and they athletes.

I had multiple athletes text me and say hey, I'm with my family, I'm.

Going to the barbecue.

I'm like I don't care.

It's a long weekend.

You do what you want.

If you go run around the park with your kid, that's fine.

And then AI is just not incorporating that.

It's like that's bringing them more joy and ready for that next workout than me saying hey, here's your formulaic program execute.

I think you and I have been well aligned on the.

We have been well aligned.

Yeah.

So I've been doing this now for a couple of years.

I dipped my toes in.

It's my side gig.

My obviously my main gig is this clinical child's operations role but it's a great side gig.

It's a whole lot of fun for me.

Have you been sad seeing the Marbella bike course?

I know that would have been your kind of thing.

It's been yes.

I wish I could go do a relay or I wish I could have qualified and then just failed on the run.

This bike course, I it's gonna shake things up for the professionals, I can tell you that much.

It's gonna shake things up.

It's gonna shake things up for everybody.

Shake things up for the age groupers, I think.

I think this course is legit.

I love it.

I wish I could ride it.

I wish I could join you there, Jeff.

I'm gonna be cheering you on.

You're gonna do great.

You're awesome at those hills.

We had so much fun last year in New Zealand.

I will definitely be missing you this year in Spain.

Stephanie, thank you so much for joining me today.

This was a great conversation.

I'm so glad that you were able to illuminate and give us the scoop on the story behind the headline.

And who knows, maybe we'll have you back and in short order to hear all about the follow up study.

It'll only be a matter of time.

It will.

Stephanie Van Beber is a Clinical Trials Coordinator in Virginia.

Tell us again the research center that you work at.

It's under Inova Health System.

It is called the inovashar Cancer center.

The Anova Shore Cancer Center.

Excellent.

I will include links where you can learn more about Stephanie, what she does, and also her coaching business in the show notes.

Stephanie, until we meet again.

I hope it'll be soon.

Thanks again for joining me today.

I really enjoyed the conversation.

Super.

Hi, my name is Denise Haslik and I'm a teammate of the Tridoc and a proud Patreon supporter of the Tridoc Podcast.

The Tridoc Podcast is produced and edited by Jeff Sankoff along with his amazing interns Cosette Rose, Anita Takeshima.

You can find the show notes for everything discussed on today's episode as well as archives of previous episodes@www.tridocpodcast.com.

do you have questions about what was discussed on this episode?

Have a question about some hot new gadget or trend that sounds too good to be true that you'd like the Tridock to sanity check on a future episode?

Send Jeff an email@tridocloud.com if you're interested in coaching services, be sure to check out tridocoaching.com or lifesportcoaching.com where you can find information about Jeff and the services that he provides.

You can also follow Jeff on the Tridoc Podcast Facebook page, Tridoc Coaching on Instagram and the Tridot Coaching YouTube channel.

And don't forget to join the Tridoc Podcast private Facebook group.

Search for it and request to join today.

If you enjoyed this podcast, do the Tridoc a solid and leave a rating and a review.

And if you haven't already, be sure to subscribe to the show wherever you download it.

And of course, of course, there's always the option to become a supporter of the podcast@patreon.com tridockpodcast the music heard at the beginning and end of the show is radio by empty hours and is used with permission.

This song and many others like it can be found at www.reverbnation.com.

be sure to visit and give small independent bands a chance.

The Tridot podcast will be back again soon to answer another medical question and chat with another amazing person in the world of multisport.

Until then, train hard, train healthy.