What is CoQ 10?

CoQ 10 (also known as: coenzyme Q10, Q10, Vitamin Q10, Ubiquinone, Ubiquinol, Ubidecarenone) is an important protein made by the body, that is involved in cellular metabolism (converting the energy from fats and sugars into usable cellular energy) and as a protective antioxidant.

CoQ 10 stimulates the immune system

Numerous studies have reported on the immune stimulating effects of CoQ 10, although the mechanisms involved in this physiologic activity are not known.

http://www.ncbi.nlm.nih.gov/pubmed/1673841?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/10416052?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/101414?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/5478631?dopt=Abstract

CoQ 10 can suppress cancer cell growth

The mechanisms involved in this anticancer activity are not known.

http://www.ncbi.nlm.nih.gov/pubmed/4218125?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/653103?dopt=Abstract

CoQ 10 protects the heart from chemotherapy injury

Studies have demonstrated that CoQ 10 can protect heart tissue from the potentially damaging effects of a commonly used class of chemotherapy drugs, called anthracyclines (i.e. doxorubicin).

CoQ 10 blood levels correlate with the risk of developing melanoma

Researchers prospectively followed 117 early stage (none with metastatic disease) melanoma patients and 125 healthy volunteers (control group), and they discovered some remarkable differences. First, the CoQ 10 levels were significantly lower in patients than in control group. Second, those with CoQ 10 levels less than 0.6 mg/L (low) had a 790% increased risk of developing metastatic disease compared with those patients who had higher levels of CoQ 10; the time to develop metastases was also almost double in patients with CoQ 10 levels 0.6 mg/L or higher! Among the 82 melanoma patients with a low CoQ 10 level (less than 0.6 mg/L), 17 of them died during the study period…whereas, none of the patients with higher CoQ 10 levels died.

http://www.ncbi.nlm.nih.gov/pubmed/16443053

CoQ 10 has been reported to enhance the efficacy of interferon therapy for melanoma

One of the standard therapies for use in patients with advanced stages of melanoma (stages 3-4) is an immune stimulating agent, interferon (IFN). IFN stimulates the immune system to recognize and attack melanoma cells. Patients with early stage disease (stages 1-2) are not typically recommended to receive IFN after surgery, as this drug is difficult for many patients to tolerate due to various side effects and the potential benefit in reducing the risk of recurrence has not well-established in these early stages.

One enterprising group of oncologists postulated that by giving CoQ 10 to those with early stage melanoma, they might be able to further stimulate the immune system. What they found was incredible:

In their study, they gave 32 patients with early stage (stage 1-2) melanoma IFN (2 injections per day of 600,000 IU) plus 400mg per day of CoQ10 for 3 years after surgery, while 49 received only interferon. The patients were monitored for five years after their treatment ended. They reported that the patients who received the IFN + CoQ10 had a reduction in their risk of developing metastases by 10-times compared with those who received only IFN. Furthermore, the IFN + CoQ 10 patients had far fewer IFN-related side effects compared with the IFN only patients; 22% versus 82%, respectively.

Other cancers that might benefit from CoQ 10 supplementation:

Very small studies and case reports have suggested that CoQ 10 may help some cancer patients live longer, including patients with cancers of the breast, pancreas, lung, colon, rectum, and prostate. Although these reports are promising, they are unfortunately not high-quality studies, therefore not much weight can be placed on these results.

Note of caution…don’t take CoQ 10 during radiation therapy:

A mouse study demonstrated reduced anticancer activity of radiation therapy when supplemented with CoQ 10. Radiation therapy works by creating free radicals in cancer cells, which then interact with the DNA and cause cell death. It is believed that by supplementing with a potent antioxidant, such as CoQ 10, the free radicals created by radiation therapy will be diminished along with its’ anticancer efficacy. Read my review article on this in the Journal of the National Cancer Institute.

CoQ 10 side effects:

None-to-mild side effects, including mild insomnia, elevated liver enzymes, rashes, nausea, upper abdominal pain/heartburn, dizziness, sensitivity to light, irritability, headache, and fatigue.

Commonly prescribed medications can lower CoQ 10 levels:

Lipid lowering medications (such as lovastatin, pravastatin, simvastatin, gemfibrozil) and the oral diabetes medications (such as glyburide and tolazamide) are well-known to reduce CoQ 10 levels. Patients taking these medications should discuss with their primary care physician supplementation with CoQ 10.

Cautionary effects of CoQ 10:

CoQ 10 may reduce the efficacy of warfarin.

CoQ 10 may reduce insulin requirements in diabetics.

As CoQ 10 has not been exhaustively researched with every chemotherapy agent or combination of agents (it’s never going to happen), recognize that there is a possibility of interactions that can either increase or decrease the anticancer effectiveness of the chemotherapy agent. Always discuss any use of supplements with your oncology team prior to using them.

Dosing:

There are no established dosing guidelines. In human studies, supplementation doses and administration schedules have varied, but usually have been in the range of 90 to 390 mg/day (most common recommendation: 100-200 mg/day)

Most absorbable form of CoQ 10:

Ubiquinol absorbs up to 8 times greater than ubiquinone, and higher levels of ubiquinol remain in the blood far longer than ubiquinone.

CoQ 10 is fat soluble. It is more effectively absorbed when taken with a meal (particularly with lipids).

Additional Resources:

National Cancer Institute PDQ: CoQ 10

About Herbs, Botanicals and Other Products (Memorial Sloan-Kettering Cancer Center): CoQ 10

Wikipedia; CoQ 10

Medline Plus (National Library of Medicine): CoQ 10 

CoQ 10 and Cancer Treatment (Life Extension)**although I like many of their products, this is still a supplement company**

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The main point on protein

You don’t have to completely eliminate dairy and meat (particularly, red meat: beef, pork, lamb) from your diet to live an anticancer lifestyle, but you will need to limit the quantity you consume. Increasingly, the results of numerous studies are consistently suggesting that the most healthful overall diet (anti-cancer, anti-diabetes, anti-cardiovascular disease, anti-inflammatory, etc.) is likely the vegan diet.

Dairy and Cancer:

• Most dairy products are high in saturated fat, which we know can lead to increased systemic inflammation, increased production of cancer-causing free radicals and weight gain.
• Learn more about FATS and CANCER on my blog post
• Since the FDA approval of the recombinant Bovine Growth Hormone (rBGH), in 1994, most dairy farms in the United States inject their cows with rBGH to increase the production of their milk. rBGH not only increases the production of milk, but it also excessively stimulates the cows’ liver to over-produce a growth factor called, insulin-like Growth Factor 1 (IGF-1). Excess levels of IGF-1 have been increasingly linked to human cancer development and growth (particularly, breast, prostate and colon cancers.) The manufacturer of rBGH reported a ten-fold increase in IGF-1 levels in milk of cows receiving the hormone. IGF-1 is the same in humans and cows, and is not destroyed by pasteurization. When you consume rBGH dairy products, the IGF-1 is not destroyed by digestion and is absorbed through the bowel into the blood. (Read more about IGF-1 and dairy)
• Learn more about SUGAR, INSULIN, IGF-1 and CANCER on my blog post
• Dairy products are high in lactose and other sugars, which increase blood sugar, insulin and IGF-1 (your liver produces IGF-1 in response to increased blood glucose and insulin.) All of these factors, when in excess, can lead to tumor development and progression (cancers love sugar…and growth factors)
• Dairy products are high in casein (casein comprises approximately 85% of milk protein, and whey protein makes up 10-15% of milk protein), which has been shown to increase tumor growth rate and metastases, in animals. It is also believed that casein may be one of the strongest cancer promoters (stimulates cancer growth) in humans, as discussed in great detail in Dr T. Colin Campbell’s international best selling book, The China Study.
• When consuming protein powders and drinks, limit or avoid those which use isolated casein as the primary source of protein. Preferentially select whey-based protein powders or drinks (studies report that whey protein may reduce the risk of various cancers, including breast cancer and colon cancer).
• Dairy products are calcium-rich. Some studies suggest that calcium intake may be linked to the development of prostate cancer.
• Consumption of dairy products can lead to lactose intolerance (affecting over 30 million adults, in the U.S.), causing diarrhea and cramping.

If you wish to consume dairy products (milk, cheese, cream, yogurt, ice cream, etc.), I recommend selecting those that are:

• organic (no hormones); they should be clearly labeled ”No rBGH” to minimize your exposure to excess levels of IGF-1
• lower fat (preferably, non-fat)
• come from grass-fed animals (producing higher amounts of omega-3 fatty acids in their milk and meat.)

Meat and Cancer:

• Most meat products (particularly, red meat: beef, pork, lamb) are high in saturated fat, which we know can lead to increased systemic inflammation, increased production of cancer-causing free radicals and weight gain.
• Learn more about FATS and CANCER on my blog post
• Most U. S. beef cattle are implanted or injected with synthetic sex hormones (estrogen, progesterone, testosterone), to stimulate growth. These hormones remain in the meat products that we consume, and it is strongly suspected that these growth stimulating hormones may be one of the key factors linking meat consumption with the increased risk of cancer development and progression in humans. (Read more about hormones in meat)
• Use of hormones is approved by the FDA for use in beef cattle and sheep.  No hormones are approved for growth purposes in dairy cattle, veal calves, pigs, or poultry. (Read the FDA information on steroid hormone use in animals…they tell us it’s all quite safe)
• Diets high in red meat increase the risk of developing cancers (colorectal, lung, breast, uterine, ovary, prostate) and cancer recurrence.
• Research demonstrates that people who eat even modest amounts of red meat have a higher risk of developing colon cancer and a higher risk of dying from cancer, or any cause.
• Processed meats (bacon, hot dogs, deli meats), likely due carcinogenic nitrites, are strongly linked to the development of numerous cancers. (Read more about cured meats and nitrites)

If you consume meat products, I recommend selecting:

• organically raised (look for ‘hormone free’ labels)
• grass-fed (higher omega-3 fatty acid composition)
• non-processed
• the best animal protein choices are fish (particularly, the omega-3 fatty acid rich fish) and poultry (skin removed)
• if you are partial to red meat, select the leanest cuts, choose moderate portion sizes, and make it only an occasional part of your diet

Eggs and Cancer:

• Although the mechanisms to explain this correlation have not been identified, there are a few studies that demonstrate an association between egg consumption and cancer risk (particularly, colorectal, bladder and prostate cancers):
• A study done in Argentina found that people consuming approximately 1 ½ eggs per week had nearly 5 times the colorectal cancer risk compared with individuals consuming less than 11 eggs per year.
• A World Health Organization study analyzed data from 34 countries and determined that egg consumption was correlated with mortality from colorectal cancers.
• In a case-control study of 130 bladder cancer patients, egg consumption was found to be associated with a 3-fold increased risk of developing bladder cancer.
• A UCSF case-control study of 3127 men with localized prostate cancer found that men who ate 2.5 eggs or more a week had an 81% higher risk of developing lethal prostate cancer compared to men who ate fewer than 0.5 eggs a week on average.
• A recent study has found that consumption of raw eggs may increase your risk of infection of certain cancer-causing viruses (14% of eggs are infected by oncogenic viruses). We are not sure of the implications on humans, but this is certainly an area of concern.

70% of the calories in eggs are from fat (mainly, saturated fat) and they are loaded with cholesterol (about 213 milligrams for an average-sized egg), I recommend that you avoid or limit your intake of whole eggs.

If you really want your egg fix, opt instead for egg whites or egg substitutes (but recognize, that since we don’t know the potential mechanism to explain if/how egg consumption may lead to cancer development, egg whites may still place you at an elevated risk.)

Can Vegans Get Enough Protein and All The Required Essential Amino Acids?

Absolutely, yes!

“Complete proteins” contain all of the amino acids needed by our body to build new proteins, cells and tissues. Only animal sources of protein are complete. Non-animal proteins are “incomplete proteins” (i.e. fruits, vegetables, grains, nuts), and are typically missing one or more of the “essential” amino acids (these amino acids are not made by the body and must be obtained from our food.)

In order for vegans to get all the amino acids needed by their body, they have to consume a variety of protein-containing foods each day. (See the Veganism Wikipedia resource list)

I have not personally chosen to move away from my omnivore diet, but I am quite convinced that the vegan diet is the best in terms of preventing cancer development and progression (not to mention its’ well-established benefits in reducing cardiovascular disease and diabetes.)

The Soy Controversy:

Soybeans (and all soy-containing products) are called phytoestogens, because they are able to weakly bind and stimulate estrogen receptors on the surface of certain cells (i.e. breast, ovary.) The active estrogenic compounds in soy are called, isoflavones (i.e. genistein and daidzein.) The concern has been that any stimulation of estrogen receptors may cause the growth of these cells; this is of particular concern if a tumor cell has estrogen receptors (i.e. breast, ovary, endometrial.)

Breast Cancer and Soy:

Recent research suggests that individuals who consume diets that are high in soy, such as those in certain Asian diets (i.e. Japanese) actually have significantly lower risk of breast cancer recurrence than in those who eat low-soy containing diets. Scientists have shown that soy contains estrogen-like molecules (“phytoestrogens”) are able to bind to estrogen receptors, thereby blocking the body’s own estrogen from stimulating the receptor. The soy estrogen only weakly stimulates the receptor, whereas the body’s estrogen (and synthetic estrogen, from medications) strongly stimulates these receptors. The net effect is that soy estrogens can significantly reduce the overall level of estrogen receptor stimulation, leading to diminished tumor growth.

• A study (published in October 2010, in Canadian Medical Association Journal) reports that postmenopausal women with a prior history of estrogen receptor positive breast cancer had a significantly lower risk (33% less!!) of breast cancer recurrence when they consumed higher quantities of soy foods compared to those women who ate smaller quantities. Estrogen receptor positivity or sensitivity means that the breast cancer is stimulated by estrogen. The authors also reported that he risk of breast cancer recurrence was further reduced in the highest soy consumption patients who were also taking a commonly prescribed hormonal anti-cancer medication (Anastrazole.)
• In a study (published in December 2009, in the Journal of the American Medical Association) which examined women with a prior history of breast, the authors reported that soy food consumption (in an amount typically found in an Asian diet) was significantly associated with a decreased risk of death and breast cancer recurrence. Importantly, these results did not vary based on the estrogen-receptor status of the tumor. This implies, that soy may be preventing breast cancer growth through an estrogen-independent mechanism.

If it were only so simple…

• It seems (based on a preclinical study) that soy consumption, when started as an adult, may decrease the effectiveness of Tamoxifen on breast cancer. If soy consumption begins in youth and continued into adulthood during and after a breast cancer diagnosis, soy significantly increases the effectiveness of Tamoxifen on breast cancer.

Prostate Cancer and Soy:

• It seems that based on accumulating evidence, consumption of soy foods is associated with a 25-30% reduced risk of developing prostate cancer.
• A small study of men with rising PSA’s after prostate cancer treatment were given a soy product (soy milk). The authors found a 50% response rate in PSA stabilization, at a median duration of 24 months.

Soy and IGF-1:

A small study of healthy postmenopausal women were randomized to receive 3 months of either soy protein concentrate (40 grams protein/day) or a milk protein concentrate (40 grams protein/day). At the end of 3 months, their IGF-1 levels were compared. The authors discovered that the women taking the soy protein had a significantly higher serum IGF-1 level (10.9 nmol/L) compared to the women on the milk protein (4.3 nmol/L). No follow-up studies have been conducted to confirm these findings nor to explore any potential association between soy protein, IGF-1 stimulation and cancer development/progression.

What Soy Foods Are Recommended?:

In Asia, soy is most often consumed in its’ minimally processed (grinding, fermenting, precipitating, boiling) and unaltered state. These foods include:

• boiled soybeans (edamame), tofu (soybean curd), natto (fermented soybeans), miso (fermented soybean paste), okara (a by-product of tofu), soybean sprouts, soymilk, yuba (by-product of soy milk), kinako (soy flour), soy sauce

If you are going to consume soy, the safest approach is to stick with these minimally-processed, soy foods. Although an area of controversy, some studies suggest an increased risk of cancer development and progression associated with the consumption of the processed, extracted isolated soy proteins. These soy isolate extracts may in fact lead to an increased stimulation of estrogen receptors, and should therefore be avoided in patients with estrogen responsive tumors (“estrogen receptor positive.”) Soy milk is often sweetened with sugar. If you are going to consume soy milk, I recommend the unsweetened versions (you can always add Stevia or other low glycemic index sweetener, if you want.)

How much protein do we need?

No one knows, as this is an emerging area of research, but it is certainly going to vary based on an individuals’ daily physiologic requirements. The Institute of Medicine recommends that healthy adults get a minimum of 0.8 grams of protein for every kilogram of body weight (or, 0.36 grams of protein per pound of body weight) per day (i.e. 58 grams for a 160 pound adult.) It is almost impossible if you are consuming enough calories (excluding cancer cachexia, severe illness/infections, starvation and other catabolic conditions) to not consume enough protein to meet our bodily requirements. In the U.S., adults get an average of 15% of their calories from protein, which, in most circumstances, exceeds their minimum daily protein requirements (i.e. for a person who requires a 2,000-calorie-per-day-diet, that’s about 75 grams of protein.)

Cancer patients who are suffering from cachexia (a catabolic/wasting syndrome), will need to increase their intake of protein, fat, and carbohydrates to prevent their body from breaking down its’ own tissues (muscle and fat) to support a much higher metabolic demand. In these circumstances, a nutritionist or dietician who is experienced in working with cancer patients should be consulted to help.

Mercury Contamination In Fish and Shellfish:

Unfortunately, there are many species of fish and shellfish that contain high-levels (i.e. greater than 0.2 parts-per-million) of mercury, a toxic, heavy metal pollutant that comes from industrial waste.

Whenever possible, select fish and shellfish that contain the lowest mercury content (i.e. canned light tuna, salmon, pollock, cod, shrimp, scallops, clams, flounder or sole) and limit your consumption of heavily contaminated species (i.e. swordfish, shark, fresh or frozen tuna, orange roughy, red snapper, grouper, lobster)

See the U.S. Environmental Protection Agency link for more information

Resources:

Harvard School of Public Health: Protein Information

American Institute for Cancer Research: Diet Information

Dr Dean Ornish: The Spectrum Diet

Zest for Life: The Mediterranean Anti-Cancer Diet: Conner Middelmann-Whitney

Foods to Fight Cancer: Essential foods to help prevent cancer: Richard Beliveau, PhD

Life Over Cancer: The Block Center Program for Integrative Cancer Treatment: Keith Block, MD

Anticancer, A New Way of Life: David Servan-Schreiber, MD PhD

Veganism: Wikipedia (excellent reference list on the bottom of the page)

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The majority of us intuitively recognize the link between stress and the immune system. How many times in your life have you come down with a cold or other viral infection shortly after periods of high-stress? Now, imagine what your body goes through when exposed to stress over years. Substantial evidence suggests that exposure to long periods of stress increases rates of cancer development and growth. How is this possible, you ask?

Stress and cancer development:

Scientists (psychoneuroimmunologists), believe that this is the end result of our chronically stressed-out brains sending stimulatory signals to our adrenal glands to produce stress hormones (like cortisol and epinephrine.) Long-term exposure of our cells to these hormones causes:

• Stress hormones increase the production of free radicals–>DNA damage and impaired immune function
• Stress hormones increase inflammation through the production of inflammatory proteins (cytokines) –>impair immune function and promote cancer growth
• Stress hormones directly impair immune cell function
• Stress hormones reduce the ability of abnormal cells to undergo apoptosis (cell death) and DNA repair, important self-regulating anticancer mechanisms
• Stress hormones stimulate the production of IGF-1 (insulin-like growth factor-1), VEGF (vascular endothelial growth factor) and other growth factors that can promote tumor cell growth

The immune surveillance theory (or, immunosurveillance theory) postulates that at any one time within an individual, there are numerous cells (precancerous and malignant) that have the potential to become a tumor if not detected and destroyed by the immune system. Fortunately, in the presence of a healthy immune system, immune cells (i.e. white blood cells, natural killer cells, macrophages) protect us by detecting and eliminate these precancerous and cancer cells as soon as they identified.  Our immune system is also constantly protecting us from viruses that can cause cancer (i.e. Epstein-Barr virus, human papilloma virus, hepatitis C virus, hepatitis B virus, human herpes virus 8 and human T-cell leukemia virus.) If our immune system is weakened or suppressed, precancerous and cancer cells and cancer-causing viruses are able to wreak havoc and eventually lead to the development of uncontrolled cancer cell growth.

Severe stress, such as occurs in individuals diagnosed with post-traumatic stress disorder (PTSD), appears to lead to permanent changes to genes (DNA) that control immune function. In a study (published in May 2010, in the Proceedings of the National Academy of Sciences) investigators have discovered that individuals with PTSD have 6-7 times as many changes to genes that control immune function compared to individuals without PTSD. Although the precise mechanism(s) to explain how these genetic changes take place is(are) not yet known, we now have data that show that PTSD can permanently change one’s DNA, reducing the function of their immune system.

It is a well-known fact that chronic stress negatively impacts the health of individuals with a variety of medical conditions (cardiovascular disease, diabetes, obesity, chronic pain, autoimmune diseases, depression, inflammatory bowel syndromes/disorders, etc.) Helping individuals with these conditions learn how to cope with and reduce stress has been demonstrated in numerous studies to not only reverse the physiologic effects of stress hormone exposure, but also significantly improve disease, overall health outcomes and quality of life. Okay, but what about the impact of stress reduction on cancer?

Stress reduction may improve cancer survival rates:

The effects of long-term exposure of stress hormones on our cells has not been definitely linked to the development or progression of cancer, but the evidence supporting this potential association is very compelling. It seems highly unlikely that chronic stress exacerbates nearly every other disease except for cancer.

An important meta-analysis (published in 1998, in Nature Reviews Clinical Oncology), of 165 studies on the topic of stress and cancer statistics (incidence & outcomes), reported that stress was associated with higher cancer incidence in initially healthy populations (6-21% higher) and higher cancer mortality (29-133% higher). The following study is one of the strongest pieces of evidence ever reported on the positive impact of stress reduction on cancer progression and recurrence:

• In a study (published in June 2010, in Clinical Cancer Research), investigators update the results of a fascinating experiment in which 227 breast cancer patients were randomly assigned to two groups: group 1 (received psychological interventions such as relaxation training and advice on minimizing stress in 39 therapy hours, over 12 months), group 2 (received no psychological interventions). The patients have been followed for over 11 years since their initial enrollment. Patients were reassessed every four months during year one, every six months during years two to five, and annually thereafter. In their initial publication, the authors previously reported that patients in the intervention group had a 45% reduced risk of breast cancer recurrence, improvements in multiple immune function measurements, and improvements in various quality of life outcomes.
• In this paper, the authors analyzed the patients who recurred in both groups. Incredibly, they found that those in the intervention group had a 59% reduced risk of death from breast cancer!!

The results of this important study suggest that a relatively short and inexpensive psychosocial stress reduction program may be effective in improving the survival of breast cancer patients.

The authors hypothesize that the mechanism for this improvement in survival and reduction in recurrence is due to the positive effects of stress reduction on the immune system.

To satisfy the skeptics out there, I want to emphasize (dare I say ‘stress’) the point that the direct association between chronic stress, the immune system and cancer has not been definitively established, but increasingly the evidence seems to support this.

While the concept of stress is universal and readily understood, it is often a challenge to operationalize it for research.  Perhaps one of the reasons for why linkages between cancer and psychological stress is not well-defined is due to the lack of clear understanding on what constitutes stress, and how stress is measured and defined. Stress is a not a distinct state of mind, but is in fact a combination of various psychological components (i.e. depression, anxiety, frustration, fear, hopelessness, etc.) resulting from exposure to adversity, cognitive appraisal, behavioral characteristics and coping style, personality, social support, and emotional responses. Each of these components may be activated by different emotional or physical experiences and can involve different neural pathways, ultimately leading to complex downstream physiological effects.

Stress reduction improves quality of life:

Regardless of whether stress reduction techniques are able to improve cancer outcomes, there is no doubt that they can greatly improve quality of life. Stress reduction techniques can involve any of variety of effective options, such as: massage therapy, meditation, guided imagery, yoga, cognitive based therapies, prayer, walking on the beach, and many others. Here are three studies looking at just one of these stress reducing modalities, yoga:

• A recent study reported that breast cancer survivors who practiced yoga for 3-months had a significant reduction in cancer related fatigue and improved vigor. This reduction in fatigue is thought to be due to yoga’s effects on the immune and neuroendocrine systems (likely through increased physical activity and stress reduction).
• A short, 4-week yoga course has also been reported to improve sleep quality and fatigue after cancer treatment.
• An 8-week yoga course was reported to reduce salivary cortisol (stress hormone) levels, improve emotional well-being and reduce fatigue after cancer treatment.

Useful References:

• Anxiety (Oncology Nursing Society)
• Caregiver Strain/Burden (Oncology Nursing Society)
• Coping with Emotional and Physical Concerns (a great reference by Cancer.Net)
• Integrative Oncology: Complementary Therapies for Pain, Anxiety, and Mood Disturbance
• Stress, Depression, The Immune System and Cancer (Lancet Oncology, in 2004. Excellent review.)
• Psychological stress and cancer (National Cancer Institute)
• Acupuncture has many beneficial effects in managing a variety of symptoms experienced in patients with cancer
• Acupuncture significantly reduces anxiety with a simple 5 minute treatment. (My blog entry on the use of acupuncture for relaxation)
• Anxiety, Fear and Depression (American Cancer Society)
• Posttraumatic Stress Disorder and Cancer
• Learn About The Impact Of Stress On Your Health & Techniques To Reduce It: Education & Self-Assessment (A fantastic reference from the University of Minnesota, Center for Spirituality and Healing and the Life Science Foundation. Not directed specifically for cancer patients, but the information is useful for everyone.)
• Stress Management (Useful tips and supplements for helping with stress, from Life Extension.org)
• Nutrients to Combat The Modern Stress Epidemic (Excellent article on the use of supplements for helping to manage stress, from Life Extension.org)
• Biofeedback Devices Help To Reduce Stress (My blog entry on the use of relaxation gizmos)
• Cannabis and Cancer (My blog entry on the use of cannabis in cancer care)

General Recommendations:

• Limit total fat intake and avoid trans fats
• Increase your intake of foods high in omega-3s (i.e. cold-water, deep sea fish and nuts, flax seed)
• Limit foods that are higher in omega-6 fatty acids (grain-fed animal meat)
• Avoid foods that are higher in total fat (i.e. fried foods, dairy products and red meat)
• Diets high in total fat increase body weight (obesity leads to an increased risk of cancer development, progression and recurrence)
• High fat foods increase the amount of inflammatory proteins in the blood (these can lead to DNA damage and suppress the immune system)
• High fat foods increase the amount of free radicals in the blood (these can cause DNA damage)
• Dairy and meat products can contain growth hormones (these may stimulate the growth of tumors).
• If you wish to consume dairy products, I recommend selecting those that are organic (no hormones), lower fat (preferably, non-fat) and come from grass-fed animals (producing higher amounts of omega-3 fatty acids in their milk and meat.) Organic, Greek yogurt with fruit makes a healthy breakfast.
• Dairy products are often loaded with saturated fat. Consider using non-fat dairy products or non-dairy options: (soy milk, rice milk, almond milk, and others.)
• If you wish to consume meat products, I recommend selecting those that are organically raised, grass-fed and non-processed.
• Limit your consumption of red meat. Red meat consumption (high in saturated fat and omega-6 fatty acids) seems to be associated with an increased risk of cancer development and recurrence.
• Corn and soy fed animals (unless the package says otherwise, they were most likely fed corn or soy) are higher in pro-inflammatory omega 6-fatty acids and saturated fats.
• Many commercially-raised, non-organic, animals are subjected to growth hormones to produce larger and faster growing animals. these growth hormones may stimulate cancer cells, as well.
• Learn more about meat and cancer here-(American Institute of Cancer Research)

“Bad Fats”

Bad fats include the trans fats (partially and fully hydrogented fats) and saturated fats:

• Try to limit your intake of saturated fats to 5-10% of your total daily calories.
• Transfats are bad. There is no reason to ever consume them.
• The risk of breast cancer almost doubles among women who have high blood levels of trans fatty acids.

• May increase the risk of colon cancer progression
• Increase DNA mutations

Fully hydrogenated fats (in margarine)

• Long-term effects not known

Saturated fats (in meat and dairy):

• Suppress immune function
• Creates free radicals
• Risk factor for dying of breast, prostate, colorectal and lung cancers

 These include the unsaturated fats (monounsaturated and polyunsaturated fats). The polyunsaturated fatty acids (PUFAs) are also known as essential fatty acids (specifically: omega-3, omega-6 and omega-9 fatty acids), as they are needed by the body (thus, essential) for cellular growth and development but have to be obtained from the diet. The body can not make these essential fatty acids. Here are the summarized details on them:

Omega-6 fatty acids (sometimes referred to as the “bad fatty acid”) are obtained predominantly from meats, poultry, dairy and vegetable oils.

Research demonstrates that the consumption of relatively high quantities of omega-6 fatty acids (versus omega-3 fatty acids) may increase the risk of developing cancer and cancer progression through the following routes:

• Omega-6 fatty acids are transformed into pro-inflammatory proteins, stimulating inflammation in the body.
• Diets high in omega-6 fatty acids increase the production of inflammatory chemicals that can: 1) stimulate tumor growth, 2) inhibit tumor cell death, 3) increase the formation of blood vessels that feed tumors, 4) increase invasiveness of tumors, 5) suppress immune function, 6) increase levels of free radicals, 7) increase the risk of developing breast, prostate, colorectal and lung cancers, increase the risk of progression and death from breast and prostate cancer
• Omega-6 fatty acids increase the production of tumor-stimulating growth factors
• Omega-6 fatty acids activate a cancer-promoting gene (ras-p21) that leads to tumor growth

It’s important to emphasize that omega-6 fatty acids are actually not “bad”, they are simply not needed in the large amounts commonly consumed in the Western diet. A healthy ration of omega-6 to omega-3 fatty acids should be in the range of 1:1 or 2:1, however the typical Western diet is in the range of 20:1!!

Omega-3 fatty acids (sometimes referred to as the “good fatty acid”) can be obtained from but are not limited to: fish and fish oils, vegetable oils (flaxseed, canola, soybean and olive oils), green vegetables, grass-fed livestock and poultry (dairy products and eggs from grass-fed animals).

There are three major omega-3 fatty acids: Alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). ALA is primarily found in certain nuts and vegetable oils, while EPA and DHA are found in dietary fish and fish oil products.

Research demonstrates that consumption of relatively higher quantities of omega-3 fatty acids (versus omega-6 fatty acids) may decrease the risk of developing cancer and cancer progression through the following routes:Omega-3 fatty acids are transformed into anti-inflammatory proteins (prostaglandins), reducing inflammation in the body.

• Diets high in omega-3 fatty acids increase the production of anti-inflammatory chemicals that can: 1) inhibit the production of blood vessels that feed tumors, 2) decrease free radicals (antioxidant), 3) supports the immune system, 4) may inhibit tumor cell progression
• Several studies discovered that omega-3s found in fatty fish (or in high-quality purified fish-oil supplements) can help slow cancer cell growth in a large number of tumors (lung, breast, colon, prostate, kidney, etc.).

Limited research demonstrates that consumption of omega-9 fatty acids may decrease the risk of developing cancer and cancer progression.

As omega-9 fatty acids are fats, you still want to only consume them in moderation.

Other References:

Dietary Fats (Medline Plus: U.S. National Library of Medicine/National Institutes of Health)

Reduced Levels of Fat in the Diet May Decrease the Risk of Breast Cancer Recurrence According to New Clinical Trial

Fat Consumption and Cancer Risk (U.S. National Cancer Institute)

Consuming foods rich in omega-3 fatty acids reduces fatigue & inflammation in breast cancer survivors 

Lots of great research articles on omega-3′s and cancer

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How does insulin work?

• prostate, breast and colorectum

What is insulin resistance?

• If you’ve developed a condition called insulin resistance (or “metabolic syndrome”), the body makes excess insulin, but the muscle, liver, and fat cells do not use or respond properly to the insulin. It is a state in which your cells are not responding to insulin appropriately, so the sugar in your blood cannot get into your cells.
• To compensate, your pancreas pumps out more insulin to try to get the sugar out of your blood and into your cells.
• The hyperinsulinimia (high blood insulin) that results is able to maintain normal blood sugar levels and delay the onset of diabetes.

What causes insulin resistance? 

• It is estimated that 1 in 4 people (without diabetes) has a genetic predisposition for insulin resistance.
• Whether or not the insulin resistance develops depends (in large part) on your eating and exercise habits.
• Not being physically active is a huge reason why insulin resistance develops.
• In addition, gaining weight/body fat (especially around the middle) is a common trigger.  And once you have insulin resistance, it’s more difficult to lose weight.  So, obesity and insulin resistance is really a viscous cycle–obesity contributes to insulin resistance, and insulin resistance contributes to weight gain!
• People who maintain a healthy weight and enjoy regular physical activity rarely develop insulin resistance, even if they have an underlying genetic predisposition.

Learn more about insulin resistance.

Should cancer patients stay away from  sugars?

Studies suggest that diets higher in the bad fats:

• Increase the risk of developing cancer (especially more aggressive cancers) and cancer progression.
• Suppress the immune system and increase inflammation in the body.
• Increase the risk of dying from numerous cancers (i.e. breast, prostate, colorectal, lung)

Bad fats include the trans fats (partially and fully hydrogented fats) and saturated fats:

• Try to limit your intake of saturated fats to 5-10% of your total daily calories.
• Transfats are bad. There is no reason to ever consume them.
• The risk of breast cancer almost doubles among women who have high blood levels of trans fatty acids.

Healthier fats include the unsaturated fats (monounsaturated and polyunsaturated fats).

• Omega-3 fatty acids are the best, followed by Omega-9 then Omega 6-fatty acids.

Did You Know That…

• Omega-3 Fatty Acids may help prevent/fight cancer.
• Reducing Inflammation may fight/prevent cancer.
• A Strong Immune System may fight/prevent cancer.
• Obesity is associated with increased risk of cancer & cancer progression

Point #2: Limit the amount of refined carbohydrates in your diet

Carbohydrates are the main source of glucose (sugar) in your diet.

• Carbohydrates get converted into glucose during digestion.

Cancer cells require sugar to grow.

• Keeping blood glucose down to a low or normal range seems to be important.

Insulin is produced whenever there is sugar in the blood.

• Individuals with high insulin levels (and an associated protein, “IGF-1″) appear to have an increased risk of cancer progression and recurrence.

Some carbohydrates raise blood glucose and insulin higher than others.

• It is important to understand their distinction.

Stay away from refined (“bad”) carbohydrates as much as possible, as these rapidly raise blood sugar and insulin (high glycemic index). These include:

• white sugar
• honey
• high-fructose corn syrup
• evaporated cane juice
• flour-based products (cookies, cakes, white bread, crackers, french fries, candy, pastries, etc.)

Complex carbohydrates are considered “good” carbohydrates because they contain vitamins, minerals, fiber, and a host of important phytonutrients (many of which have been reported to prevent and fight cancer.) Unlike refined carbohydrates, complex carbohydrates do not cause the rapid rise in blood sugar and insulin (lower glycemic index) as they are digested and absorbed.

Complex carbohydrates include:

• Whole grains (brown rice, buckwheat, wild rice, quinoa, barley, whole-wheat pasta, whole-grain bread, etc.)
• Vegetables
• Legumes (beans, chickpeas, lentils, whole and split dried peas, etc.)
• Fruit (particularly the non-tropical fruits: apples, pears, oranges, grapefruits, peaches, plums, apricots, berries, etc.)

Point #3: Limit the amount of meat in your diet.

Red meat consumption seems to be associated with an increased risk of cancer development and recurrence. 

• Corn and soy fed animals (unless the package says otherwise, they were most likely fed corn or soy) are higher in pro-inflammatory omega 6-fatty acids and saturated fats.
• Many commercially-raised, non-organic, animals are subjected to growth hormones to produce larger and faster growing animals. these growth hormones may stimulate cancer cells, as well.
• Learn more here-(American Institute of Cancer Research)

Point #4: Increase the amount of fatty fish in your diet.

These fish are high in protein and omega-3 fatty acids: 

• Cod, sablefish, salmon, mackeral, sardines, and anchovies
• Smaller fish (i.e. sardines, mackerel, and anchovies) & wild salmon have less mercury and PCBs (a toxin) than bigger fish like tuna, swordfish and shark

The risk of several cancers is significantly lower in people who eat fish at least twice a week. 

Consider taking supplemental omega-3 fatty acids, especially if you do not consume enough fish in your diet.

• Learn more about omega-3 fatty acid supplements here. 
• Find out how safe your fish-oil (omega-3) supplement is here.

Point #5: Limit the amount of dairy products in your diet.

• Treating the cancer
• Preventing recurrence
• Reducing side effects and symptoms

Integrative Oncology encourages living a healthy lifestyle to help the body in its’ innate abilities to fight and prevent cancer. This can be accomplished by learning strategies to reduce stress, increasing physical activity and eating healthfully (“anti-cancer diet & nutrition.”)
Practicing these lifestyle changes leads to beneficial “anti-cancer” effects:

• Strengthening the immune system
• Decreasing inflammation throughout the body
• Reducing (free radical) oxidative damage to cells
• Decreasing hormonal stimulation of cancer cells

Treatments are selected using a customized approach for each person by taking into account various factors:

• Cancer type and stage
• Other medical conditions
• General health status
• Symptoms
• Safety and efficacy of the treatment
• Cost and availability of treatment
• Social support
• Etc…

Selecting the most appropriate therapies for an individual is not simple, as there are many factors to consider. Coordinating the various therapies so that all of your healthcare practitioners are communicating and knowing what you are doing/taking/planning can be time-consuming, complicated and confusing.

So, your cancer treatment is over. What can you do now to reduce your risks of cancer coming back? Schedule a consultation with an integrative oncologist to help you develop a plan that is individualized to you.

Consulting with an Integrative Oncologist may be helpful, as they understand the therapeutic options that are available and they know how to navigate this process. There are multiple Integrative Oncology Centers throughout the United States.

Visit the Integrative Oncology-Essentials website to learn more.

I developed the diagrams below to help explain to my patients the core principles of integrative oncology. They show the process of how healthy, normal cells transform into cancer cells. They demonstrate how lifestyle and behaviors can influence this process and can be used to decrease one’s risk of cancer development and progression. Importantly, these diagrams shows how cancer and its’ treatment can lead to the development and exacerbation of other medical problems (Did you know that most people with cancer don’t die of their cancer? In fact, the majority of the time they die from complications of treatment or from worsening of other medical problems.) Finally, these diagrams illustrate that one can reduce symptoms (from cancer or from the treatment) by using complementary therapies or through lifestyle/behavior changes.

I hope that these diagrams help you better understand the interconnectedness and complexity of cancer care and cancer prevention.

(Click the FIGURES to see in Full-Size)

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If you are interested in learning about integrative oncology and how to reduce your risk of cancer development, recurrence and progression, I strongly recommend you watch this video. This lecture is worth your time, and it will blow your mind.

You can find the latest edition (December 31, 2009) of his book here:

Dr Servan-Schreiber discusses his book in this short 7 minute video:

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In their study, the researchers compared two groups of study participants. The first group, the yoga group, were instructed to practice a chanting meditation, “Kirtan Kriya“, every day at the same time for eight weeks. The second group, the control group, was asked to relax in a quiet place with their eyes closed while listening to instrumental music on a relaxation CD, also for 12 minutes every day at the same time for eight weeks.

Results:

“At the end of the eight weeks the researchers found that the meditation group showed significantly lower levels of depressive symptoms and greater improvement in mental health and cognitive functioning, compared with the relaxation group. In the meditation group, 65 percent showed a 50 percent improvement on a depression rating scale, and 52 percent of the group showed a 50 percent improvement on a mental health score. This compared to a 31 percent depression improvement and a 19 percent mental health improvement for the relaxation group.

The researchers also found that meditation increased telomerase activity and thus slowed cellular aging. Telomerase is an enzyme that maintains the DNA at the ends of our chromosomes, known as telomeres. Telomeres are associated with a host of health risks and diseases, which may be regulated in part by psychological stress. In the absence of telomerase activity, every time our cells divide, our telomeres get shorter and shorter, until eventually, they become so short the cells die. If high telomerase can be maintained or promoted, though, it will likely promote improvement in telomere maintenance and immune cell longevity.

In the study, the meditation group showed a 43 percent improvement in telomerase activity compared with 3.7 percent in the relaxation group.”

The Bottomline:

Yoga is an effective, non-pharmacologic approach to reducing depression, stress, improving cognitive functioning and cancer related fatigue (see additional studies below). It is clear that the healthful benefits of yoga are not simply related to practicing relaxation techniques, but also involve the integration of breath work and physical activity.

Read more about relationships between stress and cancer and physical activity and cancer.

The potential health benefits of yoga are numerous and can include:

• Stress reduction
• Increased fitness
• Management of chronic health conditions: cancer & treatment-related symptoms and side effects, depression, pain, anxiety and insomnia, fatigue, mood, blood pressure, etc…
• Weight loss

As a patient with cancer (or their caregiver), yoga can be done without requiring significant physical stamina, strength or flexibility…but you will need to find an appropriate style, instructor and class that suits your specific needs and limitations. To learn more, here’s a great guide.

Looking for a yoga class near you? Check out this useful finder.

Other interesting oncology-related yoga studies:

• A recent study reported that breast cancer survivors who practiced yoga for 3-months had a significant reduction in cancer related fatigue and improved vigor. This reduction in fatigue is thought to be due to yoga’s effects on the immune and neuroendocrine systems (likely through increased physical activity and stress reduction).
• A short, 4-week yoga course has also been reported to improve sleep quality and fatigue after cancer treatment.
• An 8-week yoga course was reported to reduce salivary cortisol (stress hormone) levels, improve emotional well-being and reduce fatigue after cancer treatment.

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Results:

The authors report significantly lower levels of fatigue (based on fatigue scores) and systemic inflammation (as assessed by finding lower levels of a blood marker of inflammation, CRP or C-reactive protein) among the breast cancer survivors who consumed higher quantities of foods containing omega-3 fatty acids and less foods containing omega-6 fatty.

Although this study is not conclusive in proving a direct link between omega-3 fatty acid intake, systemic inflammation and fatigue, it does strongly suggest this association.

Omega-3 fatty acids have multiple health-related benefits on cardiovascular disease, obesity, diabetes, inflammatory diseases, immune system support and various psychoemotional conditions (i.e. depression, anxiety and stress.) Increasingly, we are seeing more data supporting an anticancer role of omega-3 fatty acids in potentially reducing the risk of cancer development and progression (read more).

To read more about dietary recommendations regarding fats (the good, the bad and the ugly), download my free guide “Integrative Oncology Essentials.”

Bottomline:

Consuming foods that are rich in omega-3 fatty acids (and low in omega-6 fatty acids) decreases systemic inflammation, and appears to reduce cancer related fatigue. Supplementing with omega-3 fatty acids may also have similar beneficial effects.

Additional Resources and Information:

Cancer related fatigue is a topic in and of itself. Read more about it on the U.S. National Cancer Institute PDQ and in Cure Magazine.

Did you know that exercise reduces fatigue in cancer survivors? Here’s a great talk on this subject from Memorial Sloan-Kettering Cancer Center:

Saturated fats, such as those from meats and dairy products can promote  inflammation, oxidation and cancer progression:

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The Background:

• Among women with the earliest stage of invasive breast cancer (stage 1), 25% of them already have breast cancer cells that can be found in their bone marrow. (reference)
• Among men with the earliest stages of prostate cancer (pT2, no lymph node involvement, Gleason scores </=6, PSA </=4 ng/mL), over 70% of them have prostate cancer cells that can be found in their bone marrow. Even among the men who are presumed cured after prostatectomy (3 months postoperative PSA <0.4 ng/mL), 57% of them have prostate cancer cells within their bone marrow. (reference)

These and many other studies confirm that the silent (occult) presence of these metastatic cells, whether they are in the bone marrow (called, “disseminated tumor cells” or “DTC’s”) or circulating within the blood(called, “circulating tumor cells” or “CTC’s”), is not surprisingly associated with a higher rate of recurrence and death from their cancer in the future.

CTC’s are able to be detected by taking a sample of the patients blood and submitting it for analysis. DTC’s are detected by analyzing a sample of tissue taken from a bone marrow biopsy (a more painful procedure than a blood draw, and thus less desirable.)

Studies have clearly shown that not all patients with measurable CTC’s or DTC’s will go on to develop a detectable metastatic tumor. These cells may be attacked and killed by the body’s immune system, they may self-destruct (apoptosis) or they may remain dominant within the body. However, if the conditions are right they will grow into a metastatic tumor. These conditions can include:

• suppressed immune system
• inflammation
• stress
• excessive free radicals (oxidation)
• stimulation by tumor growth factors/hormones

All of these conditions are able to be modified by lifestyle changes. (described in detail on the main website, the IOE Blog and the IOE Facebook Page)

Researchers are currently studying the clinical use of tailoring cancer treatment (i.e. chemotherapy, immune therapy, etc.) based on the response as measured by following the number of CTC’s or DTC’s. This is an exciting area of research, as typically oncologists will give a cancer-killing drug for 1-3 months before assessing the response to treatment using radiographic scans (i.e. PET/CT, CT, MRI, etc.). The use of CTC or DTC analysis enables the oncologist to assess response to treatment after each dose of drug, facilitating a more rapid change to an alternative drug that may be more effective. Use of CTC’s and DTC’s to tailor cancer treatment may be one of the most important advances in the field of oncology.

The Bottomline:

Now that I have discussed the significance of these silent (occult), metastatic cancer cells, I hope that everyone reading this blog will recognize that by implementing an anticancer lifestyle you may be able to influence the biological terrain that can help keep these cells in check (dormancy or cell death.)

The future of integrative oncology research will need to include the assessment of response to specific anticancer lifestyle interventions on CTC’s or DTC’s. In the meantime (while we await years for this data to be available), there is already a substantial body of evidence to support that these healthy interventions will improve cancer outcomes…so don’t delay, and get on the anticancer bandwagon now.

Learn more about CTC’s:

What is the clinical relevance and biology of CTC’s? (Breast Cancer Research: review article)

The latest technology in capturing and analyzing CTC’s

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This is a completely apolitical blog entry on the science of the medical efficacy of Cannabis (marijuana) in oncology.  Cannabis is plant that is classified in the U.S. as a controlled substance with an “increased potential for abuse and no known medical use” (Schedule 1). By federal law, possessing Cannabis, is illegal in the U.S.  Although U.S. federal law prohibits the use of Cannabis, 16 states and the District of Columbia permit its use for certain medical conditions with a physicians’ prescription. That said, doctors in these states may not legally do so without violating federal law and can lose their federal license to prescribe drugs and prosecuted. Presently, 3 states (Colorado, Maine, and New Mexico) license producers and distributors of medical cannabis. Now that I have established that, let’s learn more.

What are the active compounds in Cannabis?

There are over 400 chemical compounds that have been discovered within the Cannabis plant. The phytocannabinoids (or simply,” cannabinoids”) are the main chemical components that exert most of the pharmacological activity of the plant. There are more than 60 identified cannabinoids, but the 4 most well-studied and characterized cannabinoids are delta-9-tetrahydrocannabinol (d-9-THC), cannabidiol (CBD), cannabinol (CBN), and tetrahydrocannabivarin (THCV).

Cannabinoid compounds are currently available as either synthesized chemicals or whole plant extracts, including:

• Dronabinol (Marinol): U.S. FDA-approved, synthetic THC pill
• Nabilone (Cesamet): U.S. FDA-approved, synthetic THC pill
• Nabiximols (Sativex): not yet approved by the U.S. FDA (approved in Canada and in the UK), natural tincture spray containing both THC and CBD

Perhaps the most exciting area of cannaboid research involves the discovery of the body’s endocannabinoid system. Incredibly, our bodies make their own cannabinoid chemicals which interact and stimulate cannibinoid receptors on our cells. Studies continue to uncover the numerous functions of our endocannabinoid system, including:

• anti-inflammatory activity: anticancer
• antioxidant activity: anticancer
• inhibiting tumor cell growth (apoptosis): anticancer
• inhibiting blood vessel growth to tumors (anti-angiogenesis): anticancer
• antiviral activity
• involved in learning and nervous system plasticity
• pain processing
• neuroprotective effects
• visual perception
• immune system modulation: anticancer

Routes of use of Cannabis:

Cannabis may be taken by mouth (i.e. baked products, butters, teas, liquid sprays and tinctures, gum, beer, etc.) or may be inhaled, through smoking or vaporizing (read my blog entry on vaporization). One of the most safe and consistent methods of obtaining a controllable dose of active drug when using Cannabis is through vaporization.

It takes over one hour for Dronabinol (Marinol) to reach full systemic effect, compared to minutes for smoked or vaporized cannabis.

Uses of Cannabis in oncology:

As an integrative oncologist, I recommend the use of various methods for helping patients manage commonly encountered side effects and symptoms of cancer treatment and the cancer itself. Whenever possible, I start by suggesting non-pharmacologic therapies that have been shown to be effective, safe and are inexpensive. If the symptoms are moderate-to-severe or unlikely to be able to be controlled with non-pharmacologic approaches, this is when I will recommend using natural botanical products and/or pharmaceutical drugs.

5 commonly experienced symptoms in cancer patients are:

• nausea
• diminished appetite (and associated weight loss)
• pain
• sleeping difficulties
• psychoemotional distress (i.e. anxiety, stress and depression).

Cannabis (as the whole plant compound) and the synthetic and extracted delta-9-tetrahydrocannabinol (d-9-THC) and cannabidiol (CBD) have all been shown to have significant efficacy in improving these 5 common symptoms in clinical trials.

Your physician would need to prescribe 5 different drugs to (with the associated side effects and costs) to manage these symptoms…or you they can prescribe one drug which improves all 5 symptoms.

If only one or two of these symptoms are causing significant problems, I typically don’t recommend using a cannabinoid since other pharmacologic options may be more effective in treating those individual symptoms. Unfortunately, it is quite common to see patients with the majority of these symptoms manifesting at once (particularly in advanced stages of disease and treatment). For these patients, I think it is very appropriate to recommend a cannabinoid or Cannabis by itself or in combination with other pharmacologic (i.e. Megace for poor appetite, Zofran for nausea, etc.) and non-pharmacologic therapies (i.e. mind-body therapies, etc.)

Recently reported data indicate that the combination of inhaled Cannabis (via vaporization) with opioid pain medications leads to a synergistic affect, which decreases the amount of opioids needed for pain control. This synergistic action helps patients by reducing the side effects of higher dose requirements of opioids (i.e. sedation and nausea).

Is there any validity in the use of Cannabis as an anticancer agent?

There are no quality clinical studies in humans that have been done for us to know if Cannabis or any of the cannabinoids are able to improve cancer-specific outcomes (i.e. survival, recurrence, progression).

There are interesting and promising preclinical studies (using cancer cells or animal studies) that demonstrate the anticancer activity of cannabinoids:

(from the U.S. NCI PDQ: Cannabis and Cannabinoids):

• “Studies in mice and rats have shown that cannabinoids may inhibit tumor growth by causing cell death, blocking cell growth, and blocking the development of blood vessels needed by tumors to grow.”
• “Laboratory and animal studies have shown that cannabinoids may be able to kill cancer cells while protecting normal cells.”
• “A study in mice showed that cannabinoids may protect against inflammation of the colon and may have potential in reducing the risk of colon cancer, and possibly in its treatment.”
• “A laboratory study of delta-9-THC in hepatocellular carcinoma (liver cancer) cells showed that it damaged or killed the cancer cells. The same study of delta-9-THC in mouse models of liver cancer showed that it had antitumor effects. Delta-9-THC has been shown to cause these effects by acting on molecules that may also be found in non-small cell lung cancer cells and breast cancer cells.”

According to a 1995 review prepared for the World Health Organization, “There are no recorded cases of overdose fatalities attributed to cannabis, and the estimated lethal dose for humans extrapolated from animal studies is so high that it cannot be achieved by … users.”

In 2008, investigators at McGill University and the University of British Columbia reviewed 23 clinical investigations of medical cannabinoid drugs (typically oral THC or liquid cannabis extracts) and eight observational studies conducted between 1966 and 2007. Investigators “did not find a higher incidence rate of serious adverse events associated with medical cannabinoid use” compared to non-using controls over these four decades.

Pharmacologic studies indicate that a human would need to eat 1,500 pounds of Cannabis within 15 minutes to achieve lethal levels of cannabinoids.

That said, cannabinoids are active drugs with potential side effects and risks.

Potential side effects of cannabinoids may include (from the NCI PDQ):

• Rapid beating of the heart.
• Low blood pressure.
• Muscle relaxation.
• Bloodshot eyes.
• Slowed digestion and movement of food by the stomach and intestines.
• Dizziness.
• Depression.
• Hallucinations.
• Paranoia.

Both Cannabis and cannabinoids may be addictive. Symptoms of withdrawal from cannabinoids may include (from the NCI PDQ):

• Restlessness.
• Hot flashes.
• Nausea and cramping (rarely occur).

References on safety and risks:

• Here is an up to date reference on these side effects and risks for Dronabinol (Marinol).
• What is the risk of Cannabis use on developing cancer?
• (NORML.ORG)
• (U.S. NCI PDQ)

Clinical Trials of Cannabis or Cannabinoids in Cancer

In preparing this blog entry, a search of the U.S. NCI Clinical Trials website (with search keywords: cannabis, cannabinoid, THC) identified 5 registered phase 2 and phase 3 clinical trials that are currently active or approved for studying the effects of these agents in patients with cancer. Unfortunately, none of these studies involves the use of the whole plant (Cannabis).

Clearing the Smoke: The Science of Cannabis

MontanaPBS’s new documentary, Clearing the Smoke, reveals how cannabis acts on the brain and in the body to treat nausea, pain, epilepsy and potentially even cancer. Extensive interviews with patients, doctors, researchers and skeptics detail the promises and the limitations of medicinal cannabis. (57 minutes. February 2011)

The Science of Medical Cannabis: A Conversation with Donald Abrams, M.D.

Marijuana Gateway to Health: How Cannabis Protects Us from Cancer and Alzheimer’s Disease

Clint Werner is a recognized expert in the science, history and politics of Cannabis. This excellent book is a review on everything you ever wanted to know on this subject. It is up to date, scientific and factual, which appealed to me over a biased rant. (published: September 2011).

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It’s a touching story about a classmate of Charlie Brown and Linus, Janice, who gets diagnosed with leukemia. In typical Peanuts fashion, the story not only educates us (and our children) about the disease (symptoms, diagnosis, treatment, side effects) but, Charles M. Schulz instills wonderful messages of empathy, compassion and strength throughout the 28-minute episode. I rate this two thumbs up!!  (Shamelessly, I am sharing this with you after discovering it on a fellow blogger’s site.)

Helpful resources on pediatric cancers and integrative cancer therapies for children:

American Cancer Society: Cancer in Children 

U.S. National Cancer Institute: Pediatric Cancer Information

Cure Search for Children: Children’s Oncology Group

Cancer.Net (Childhood Cancer): American Society for Clinical Oncology

Integrative Therapies Program for Children with Cancer: Columbia University Medical Center

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Background:

In some studies, depression has been associated with poorer survival outcomes in those with cancer. In one recently reported study, of 125 women with metastatic breast cancer, the researchers discovered that the women with lower depression scores (least depressed) had a significantly longer survival time compared with the more depressed women (53.6 months versus 25.1 months).

Although depression and cancer progression has yet to be definitively linked, the data is hard to ignore. We know that depression and reduced treatment compliance (i.e. following up on medical appointments, examinations, treatments, etc.) are directly related. Furthermore, we know that depression negatively impacts the body’s immune system and may increase tumor progression through a complex interplay of neurohormonal and inflammatory pathways. (read more here)

Incredibly, simply teaching patients how to cope with the psychoemotional distress of their cancer has been shown to improve cancer-specific survival. In one study of 227 women with breast cancer randomized to either an intervention arm (teaching coping strategies) or control arm, the authors reported a significant reduction in the rates of breast cancer recurrence (45% lower) and death (55% lower) among the women in the intervention arm.

As quoted from a recent Journal of Clinical Oncology article, “Pain and symptom distress, mood disorders, and family caregiver burden are prevalent and carry significant adverse consequences for our patients and their families. Medical care focused on addressing these burdens—pain and other symptoms, mood disorders, and matching care to honestly informed and achievable goals—not only improve quality of life and reduce depression but, as recent studies suggest, may also improve survival. In addition, such interventions pose low or no risk and, compared with other cancer treatments, are low in cost.”

What can be done?

I strongly encourage oncology providers to start assessing for depression in their patients, today. Simple tools have been developed and validated to help in this diagnosis. One of which is the nine-item depression screening tool, PHQ-9 (Patient Health Questionnaire-9), which can be quickly self-administered in the office or at home. It is available here free of charge as a download, and has been translated in many languages. Simply asking our patients “How are you coping?” is a crucial part of our care. I can’t begin to tell you how important simply asking this question has been in so many of my patient interactions. Sadly, I am often the only one who has asked them this question. If you are concerned about how much time this may take out of your tight clinical schedule, trust me I get it but we have to open this door for them. You might be the only one to show them how much you care about their distress, and you absolutely can help them. Your display of empathy and compassion, by inquiring about this common distress starts the dialogue and is the first step to healing.

Involving mental health providers, social workers and nurses in helping our patients cope with their psychoemotional distress is the next step, as treating depression may not be a straightforward intervention. Depending of the severity of the symptoms, there are many therapeutic options available: medications, botanical compounds, exercise, diet modifications, sleep hygiene, talk therapy, support groups, and numerous complementary therapies (i.e. acupuncture, massage, yoga, meditation, reiki, etc.).

Just as much as our conventional oncologic treatments (i.e. chemotherapy, radiation therapy, surgery, etc.) are essential in the management of our patients’ cancer, so is our responsibility to identify and address this common problem.

**As pointed out by one reader of this blog, this also applies to the caregiver. CURE magazine has published a great issue on this topic.**

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Most oncologists suggest to their patients that they simply consume a diet containing a wide-variety of phytonutrient compounds. Although this is certainly a safe (first do no harm) recommendation, it is very challenging for most individuals to consistently eat enough anticancer foods to load their blood and tissues with ‘effective’ concentrations of nutrients and anticancer compounds. This is where using a variety of natural supplements may be useful.  As an analogy, oncologists prescribe the chemotherapy drug Taxol (derived from the bark of a Yew tree) as a high-dose, concentrated agent. To achieve a similar efficacy, one would need to consume pounds of Yew tree bark each day to potentially achieve any significant clinical efficacy…imagine the low level of compliance of following this regimen.

As one of my colleagues, Dr. Jeffery Blumberg (Director of the Antioxidants Research Laboratory at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University) has been quoted: “The average diet is poor when it comes to meeting recommended intakes of vitamins and minerals. Only about 3% of Americans adhere to the dietary guidelines. How many Americans do you know who eat five to nine servings of fruits and vegetables a day and consume at least 50% of their grains as whole grains? If you are eating a perfectly healthful diet, then you don’t need supplements. But for the 97% who aren’t there yet, for goodness sake, take a multivitamin.”

The rationale for recommending a diet containing a variety of anticancer phytonutrient compounds is the same for why oncologists often prescribe a multi-drug regimen, enabling a multi-pronged attack on more than one critical function in the cancer cells at the same a time. This multi-drug approach has significantly improved clinical outcomes in cancer control.  Almost every day, I read new studies that demonstrate promising anticancer activity from natural compounds (i.e. EGCG, curcumin, etc.). Unlike the majority of chemotherapeutic agents, many of these natural compounds affect cancer cells from multiple pathways. The example I show in the diagram below illustrates a sample of the important cancer-promoting mechanisms (‘purple’ bubbles), that when not tightly regulated, can lead to tumor development and progression. Regulation of these mechanisms is controlled by numerous proteins and receptors (‘green’ bubbles), which can be influenced by natural dietary compounds.

Examples of nutrient compounds with anticancer activity on the regulatory proteins/receptors above:

• Inhibition of NF-kB: (resveratrol, curcumin, EGCG, isoflavones, omega-3 fatty acids, vitamin D3, pomegranate extract, ashwagandha, gingerol, milk thistle, lycopene)
• Reduction in 5-LOX: (omega-3 fatty acids, boswellia extract/AKBA, curcumin, lycopene)
• Inhibition of Ras: (curcumin, limonene, vitamin E, garlic extract/diallyl sulfide)
• Reduction in COX-2: (omega-3 fatty acids, berberine, feverfew, gingerol, EGCG, curcumin, resveratrol, milk thistle, gamma tocopherol)
• Inhibition of Caspases: (cucumin)
• Inhibition of PARP: (curcumin)
• Inhibition of AMPK: (curcumin)
• Inhibition of Galectin-3: (modified citrus pectin)
• Inhibition of E-selectin: (alpha-linolenic acid, omega-3 fatty acids)

Where do we go from here?

I am increasingly of the mindset that a rational approach to the use of various supplement compounds (each with different mechanisms of action) could provide benefit for our patients. A rational approach is one in which the selected supplements have the potential for benefit (based on preclinical and/or clinical data), have a low probability for harm and are taken with the knowledge of your oncologist. Consume as many of these natural anticancer compounds in their whole foods form, as there are often numerous anticancer compounds that are not present in isolated extracts. However, I suggest taking certain supplements in circumstances when it may not be realistic to consistently achieve therapeutic levels of specific anticancer compounds from consuming the whole food.

Which supplements should I take? What dosage? What are the safety concerns?

These are the multi-million dollar questions. As another one of my colleagues, Dr Keith Block (Director, The Block Center For Integrative Cancer Treatment) says: “When faced with a serious medical challenge like cancer, you should not assume that nutritional and herbal supplements are risk-free.  Safety (and, by extension, efficacy) issues should always come first.  Particularly if you have cancer, it’s important to seek out the expertise of someone who understands how supplementation strategies can be potentially problematic, and how their inappropriate use can hinder, rather than bolster, your plans for treatment and recovery. Lastly, it is important for you to discuss any and all supplements you are taking with your healthcare provider.  Ideally, a supplement protocol will be individualized to your unique needs and regularly monitored and modified, as necessary.  This is usually best accomplished with a physician or clinical expert who has extensive experience with the use of these integrative strategies.

The bottomline:

Attacking cancer with an evidence-based, multi-pronged, individually-tailored nutrient regimen can be safely implemented with the help of a knowledgeable integrative provider. While we await (years-decades) for scientists to study the anticancer efficacy in natural compounds, a rational approach can be implemented today. Conventional oncologic therapies (i.e. surgery, chemotherapy, radiation therapy) should not be dismissed in favor of an alternative approach (i.e. dietary-alone). Instead, combining various therapies (i.e. conventional therapies, dietary therapies, physical activity, stress reduction, etc.) should be the standard of care for everyone who has been diagnosed with cancer. This complex, but rational approach is best coordinated by a multi-disciplinary team who regularly communicate with each other regarding their mutual patients. This is the field of integrative oncology.

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Stomach 36 (or “ST 36″) is my favorite acupuncture point for treating nausea. I feel that this point is even more effective than Pericardium 6 (“P 6″), on the underside of the wrist. ST 36 is located by finding the bump on your tibial (shin) bone about one inch below the knee. This bump is called the tibial tuberosity. ST 36 is level with the bottom of the tibial tuberosity, one thumb width towards the outside of the leg. When you press firmly on this point (it is in the muscle), you can often feel an achy sensation (called “de qi”).

Take your lit and glowing moxa roll and hold it over ST 36 for a few seconds until you feel the heat sinking in, then pull it away from the skin to cool it down. You can do this on either or both legs, and it can be done repeatedly for a few minutes (i.e. going back and forth between the right and left ST 36 points). You should feel the nausea abating after a few minutes.

Moxa rolls are inexpensive, easy to use and are a great way to help relieve nausea without any side effects.

You can purchase moxa online or through stores in your local Chinatown. Here are a few recommended online suppliers:

• Lhasa OMS
• Acu-Market
• GoAcupuncture

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In light of the recently reported SELECT study, many patients are asking this question. Here is my short response:

Bottomline:

Risk factors for DVT’s and VTE’s:

DVT’s and VTE’s occur much more commonly among those with certain risk factors: cancer, obesity, inactivity, history of a prior stroke (or transient ischemic attack, TIA) or heart attack, coronary artery disease, hypothyroidism, systemic inflammation, smoking, elevated LDL and total cholesterol levels, low HDL levels and a variety of other hypercoagulable conditions.

How does cancer increase the risk for blood clots?

• Cancer cells produce coagulation and inflammatory proteins that can lead to a hypercoagulable state.
• Certain medications used to treat cancer (i.e. tamoxifen, bevacizumab, thalidomide and lenalidomide) can increase the risk of blood clots.
• Inactivity (associated with deconditioning, fatigue and/or pain during and after cancer treatment) can lead to increased stasis or pooling of blood in the legs, a known risk factor for formation of DVT’s. Inactivity can also increase the risk of obesity and systemic inflammation, known risk factors for blood clots.
• A recent surgery or hospitalization is the most common risk factor for developing DVT’s (typically as a consequence of prolonged inactivity leading to blood stasis in the legs and pelvis.)

How do you decrease your risk of DVT and VTE?

As an integrative oncology colleague and friend of mine is often quoted saying “…most cancer patients don’t die from their disease, they unfortunately and unnecessarily can die from the complications associated with the disease and its related treatments.”- Dr. Keith Block, Medical Director, The Block Center

Integrative oncologists spend time counseling our patients on these complications, and teaching them the warning signs, risks and offering suggestions on how to reduce these risks.

Here are my recommendations to help reduce the risk of DVT and VTE:

One of the most effective therapies to help reduce the severity and pain of mucositis comes from the good ol’ honey bee: pure natural honey.

The viscous nature of honey makes it a great protective barrier that coats the delicate mucous membranes of the mouth and throat. It is inexpensive and has no side effects. Honey also has natural bactericidal properties that help protect against increased colonization by bacteria and fungal organisms.

Here’s a great link to an article on “Honey in Medicine“

Data:

One of the best studies that examined the efficacy of honey for reducing mucositis, randomized 40 head and neck cancer patients to prophylactic treatment with or without the use of topical pure natural honey during their radiation and chemotherapy. The researchers demonstrated a large reduction in the risk of developing moderate-to-severe (grades 3 & 4) mucositis among those using honey (15%) compared to those not using honey (65%). Furthermore, honey use was also significantly correlated with a much lower risk of yeast (candida) colonization (15% vs. 60%) and bacterial colonization (15% vs. 65%).

The Bottomline:

For patients who are at risk of developing mucositis (mouth/throat), definitely keep this natural remedy in mind as one of the first things you try. If honey is not effective for you, your cancer care team can provide you with many other therapeutic options.

I provide some helpful links on mucostis treatments here.

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Although the mechanism of action of metformin in diabetes is only partially understood, metformin treatment reduces levels of both blood glucose and insulin. The primary mechanism of action in diabetes is on the liver through reduced production of glucose. (ref)

Scientists have recognized for years that certain cancers (i.e. breast, prostate, colon, endometrial, pancreatic, lung, etc.) thrive in the presence of elevated blood sugar and insulin levels, eventually leading to higher rates of tumor development, progression and metastases. By keeping blood sugar levels low (either by diet or medications), cancer development and progression is impaired. (I have written more extensively about the role of sugar and insulin in cancer development and progression on the IOE website.)

Anti-cancer effects of metformin:

Over the last decade, numerous studies have discovered that metformin (compared with other glucose-lowering therapies) appears to have powerful anti-cancer effects that extend far beyond simply lowering blood sugar and insulin: (ref) 

• activation of AMP-kinase (AMPK):
• AMPK inhibits glucose production in the liver (indirectly reducing insulin and insulin-like growth factor, IGF-1, levels)
• AMPK increases insulin sensitivity (reducing blood sugar levels) by increasing glucose uptake in muscle
• AMPK activation blocks gene expression of cancer promoting proteins, leading to inhibition of tumor cell growth (induction of cell cycle arrest and apoptosis)
• AMPK inhibits the genetic signaling of the molecular complex, mTOR (mTOR activation is implicated in cancer development and chemotherapy resistance)
• suppression of human epidermal growth factor receptor-2 (HER-2)
• selective killing of cancer stem cells (often chemotherapy resistant cells)
• aromatase inhibition (decreasing estrogen production in the body)
• increases the effectiveness of chemotherapy (higher pathologic complete response) and radiation therapy (radiation sensitization)
• significantly decreases body mass index (via effects of maintaining lower blood sugar levels and appetite suppression); obesity increases systemic inflammation, estrogen levels, free radicals (all of which can stimulate cancer growth and progression)
• lower blood sugar levels maintain lower insulin secretion (insulin and its’ associated hormone, IGF-1, are tumor growth factors)

Metformin & breast cancer:

• 56% reduction in the risk of developing breast cancer among those taking metformin versus not taking metformin (ref)
• 24% of diabetics breast cancer patients taking chemotherapy with metformin had a complete remission versus 8% who were not taking metformin (ref)

• Anxiety Disorders
• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Cardiac-related morbidity and mortality
• Cognitive impairment
• Coronary heart disease
• Depression
• Chronic pain
• Diabetes
• Digestive problems (i.e. IBS, etc.)
• Immune suppression (leading to increased susceptibility to viral infections, etc.)
• Inflammation
• Insomnia
• Headache (migraine and tension)
• Hostility
• Hypertension
• Memory impairment
• Sedentary Lifestyle
• Skin problems (i.e. eczema, etc.)
• Stress
• Substance Abuse

Effects of Chronic Stress:

Periods of long-term exposure to stress wreaks havoc on nearly every cell type in the body. Stress activates the sympathetic nervous system (SNS), which through elevated levels of stress hormones (i.e. cortisol, norepinephrine, etc.), free radicals and inflammatory hormones directly and indirectly damage DNA, stimulate tumor growth and metastasis and suppress the immune system. (I have written about the science of this previously: here)

Stress Reduction Through Breathing:

It is well-recognized that by practicing stress management and relaxation techniques, individuals can decrease their SNS stimulation while increasing parasympathetic nervous system (PNS) stimulation- a state referred to as the “relaxation response.”  We are able to turn on the relaxation response by activating our vagus nerve, the longest nerve in our body (extending from the brain stem to the base of the spine and to several organs and your heart) by learning to change our breathing and learning to change our focus.

(Listen to an audio discussion on this trend)

This procedure is most compelling to those patients with an increased risk of developing a contralateral breast cancer (i.e. BRCA 1/2 gene mutations, strong family history of breast cancer, prior exposure of radiation to the breast, etc.), although CPM will significantly reduce the risk of developing a contralateral breast cancer in all patients (there is always a small amount of residual breast tissue remaining even after a mastectomy, and tumors can develop in this tissue.)

Even in women who have none of the above risk factors placing them at an increased risk of developing a contralateral breast cancer, many express that they simply want to avoid having to go through repeat imaging studies (and possible biopsies), and subjecting themselves to the fear of recurrence and/or discomfort of these procedures. Others feel that having a CPM will leave them with more symmetry (particularly if they have larger breasts) and may help them obtain a better cosmetic outcome if they choose to have reconstruction. In one recent study, investigators reported that only 13% of women who underwent CPM had BRCA mutations or previous radiation exposure — the 2 factors that are associated with an increased risk for contralateral breast cancer and are accepted indications for the procedure.

As an oncologist, I feel that the decision to undergo CPM is one that should be made with a complete understanding of the data. Whatever decision feels right to the patient is valid and must be respected. Here are some facts:

What is the risk of developing a contralateral breast cancer in an intact breast?

• Annual rate of developing a contralateral breast cancer is 0.1-0.3% (0.2-0.7% annual rate for women with hormone receptor-negative first tumors).

Does adjuvant hormonal therapy reduce the risk of developing a contralateral breast cancer?

Do women remain satisfied with their decision to undergo CPM years later?

• The majority of women (approximately 85%) continue to have an overall high-degree of satisfaction regarding their decision to undergo CPM (10 year follow-up).
• The majority of women experienced no change or favorable effects in self-esteem (83%), level of stress in life (83%), and emotional stability (88%).
• A large minority (33%) described a negative impact on their appearance, feelings of femininity (26%) and effect on sexual relations (23%).
• Among women who underwent CPM with breast reconstruction, the majority (90%) would choose the same reconstructive procedure again.

What is the risk of complications following CPM with breast reconstruction?

• Surgical complications and rates of additional surgery in breast reconstruction range from 10-50%.
• Implant reconstructions are associated with a higher risk of reoperations than tissue transfer reconstructions.
• Reoperations are performed for various reasons: postoperative complications (i.e. infections, hematomas etc.), implant-related issues, aesthetic concerns (non-implant related), etc. Implant contracture is the most common indication for reoperation.
• Most reoperations occur within the first year of the reconstruction.
• Chronic pain (persisting at least 2 years) after mastectomy and reconstruction is a frequent problem, affecting up to 70% of women. This can negatively impact on sleep (in 36% patients) and daily activities (in 22%).  10-15% of women can experience severe, long-lasting pain.

In summary:

Deciding whether or not to undergo a CPM at the stressful time of diagnosis can be overwhelming for many patients who are just beginning to cope with the reality of their cancer diagnosis. Whenever possible, the cancer care team members need to express to their patients that they have time to think about their surgical management and obtain second opinions. They need to hear the facts and have time to think about their options. Whatever decision they make regarding CPM, the oncology team should support.

Additional Resources:

Fibrosis can develop months-to-years after radiation therapy to any region of the body, but is most common in the extremities, breasts (read more about implant contracture, below) and head and neck where higher radiation doses are often required on or just below the skin surface.

How does this treatment work?

It is not entirely clear how these molecules work to reduce fibrosis. Vitamin E may act as a antioxidant, helping to prevent ongoing free radical damage to the radiated tissues. Pentoxifylline may be involved in blocking the molecular signaling pathway that is responsible for the development of fibrosis as a response to inflammation and injury. Additionally, pentoxifylline increases the flexibility and permeability of red blood cells which enables them to more easily bring oxygen to the tissues and carry carbon dioxide away. It is because of this mechanism that pentoxifylline is used in the management of peripheral artery disease, leg ulcers, strokes, high-altitude sickness, eye and ear disorders, and sickle cell disease and diabetic neuropathy.

Results of treatment:

Significant improvement in pain, tightness, muscle strength, edema and range of motion have all been reported with this treatment.

It seems that the earlier that this treatment is started after the development of fibrosis the quicker the response, however this combination therapy is still effective (approximately 60-70% reduction in fibrosis) even when started many years after radiation therapy.

Have patience:

It is important to recognize that this medication combination can take 6-48 months to achieve the best possible results.  In one study, it took a median of 16 months to achieve a 68% reduction in fibrosis for those who started treatment within 6 years of completing radiation therapy and a median of 28 months for those who started treatment greater than 6 years after completing radiation therapy. Relapses were found to occur more commonly among patients who took this treatment for less than 12 months.

Duration of treatment:

• For severe skin fibrosis, I recommend that treatment continue for 3 or more years.
• For mild-to-moderate fibrosis, I recommend that treatment continue for at least 1 year.

An increasingly common issue: Breast implant contracture following radiation therapy

As more patients undergo breast reconstruction (with either tissue transfer/rotational techniques or implant prostheses), it has become more common in oncology and plastic surgery practices to have to address breast cancer treatments in this setting.

All patients with breast implants or expanders will eventually develop scar tissue (fibrosis) surrounding the prosthesis as a consequence of the body’s normal immune/inflammatory response to a foreign body. This fibrotic response varies in severity among individuals, but it is estimated that up to 25% of women with breast implants undergo revision surgery (at 10 years) due to implant contracture (shrinking and or hardening of tissue surrounding the implant).  Following radiation therapy, implant contracture rates are increased due to the effects of radiation fibrosis. (picture on left: This patient developed an implant contracture after radiation therapy to to her right breast and implant. The superior implant displacement and circumferential tightening are common findings.)

Although the rates or lower in women who select breast reconstruction with their own tissues (tissue transfer or rotational techniques), they are also at a higher risk of developing contracture and fibrosis of their reconstructed breast after radiation therapy to these tissues.

Vitamin E and pentoxifylline are being investigated as a prophylactic therapy to reduce the incidence and severity of implant contractures or implant loss after receiving radiation therapy to the chest wall or breast in the setting of breast cancer treatment. The results of these investigations will be important in helping us better direct our management of this condition.

Starting this treatment during radiation therapy is not recommended, as vitamin E may reduce the efficacy of radiation. 

Bottomline:

Vitamin E and pentoxifylline is a useful therapy for patients with radiation-induced fibrosis. It can reduce the signs and symptoms of this condition dramatically in the majority of those who continue taking it for at least 6-12 months (or longer in cases of severe, long-standing fibrosis.)

The use of vitamin E and pentoxifylline following radiation therapy to reduce the risk of breast implant contracture and failure is under investigation.

If you think that you might benefit from a course of vitamin E and pentoxifylline, discuss this with you radiation oncologist.

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It seems that this question is coming up more often these days among patients who have completed treatment for prostate cancer.

The Background:

Very effective direct to consumer marketing campaigns touting the benefits of TRT and “bio-identical hormone therapy” (i.e. Dr Life’s Cenegenics, BodyLogicMD, etc.) have peeked the interest of many men who are starting to feel the mental and physical effects of ‘aging’. Popular TV news, talk shows and radio programs have spread the word about so the called “male menopause” or “andropause”.

As part of the natural aging process, men after the age of 30 men begin to lose testosterone at a rate of 1-2% per year.  By the time a man reaches 70 years old, his testosterone (T) level can be only 10% of that of a 25 year old.  Although very common among men over 60, andropause can present in men in their 40′s and 50′s (in one recent study, 39% of men >/= 45 years old were considered to be T deficient). The most common cause of andropause is low T, however multiple other hormonal factors can also be responsible. Blood, urine and/or salivary tests are used to help diagnose the and follow the levels of these hormones.

Classic symptoms of andropause (known as ‘hypogonadism‘ in the medical literature) can include the following: increased irritability, depression, memory loss, fatigue, hot flashes, night sweats, weight gain, muscle loss, diminished libido, erectile dysfunction, hair loss, etc.

If you are being told that adding a little T to your life might make you feel and look better, who can blame you for asking more about it? Heck, where do I sign up!?

Unfortunately, simply making a diagnosis of andropause and correcting hormone levels may have minimal-to-little effect on these symptoms. It is important to recognize that the cause of each of these symptoms is typically difficult to pin-down. More often than not, they are attributable to a complex interplay of multiple factors including other medical (i.e. diabetes, heart disease, medication side effects, cancer treatment side effects, etc.) and psychoemotional (i.e. stress, anxiety, depression, etc.) conditions and lifestyle factors (i.e. poor nutritional/dietary habits, lack of physical activity, smoking, excessive alcohol consumption, etc.) that should be addressed.

Risks associated with low T:

Low T is associated with an increased risk of 3 serious medical conditions:

• Cardiovascular disease:
• Low T is associated with: increased levels of total cholesterol, low-density lipoprotein, increased production of proinflammatory factors, and increased thickness of the arterial wall and contributes to endothelial dysfunction.
• TRT is associated with: improved arterial vasoreactivity, enodothelial function and reduces proinflammatory cytokines, total cholesterol, and triglyceride levels
• Metabolic syndrome and type 2 diabetes/insulin resistance:
• Metabolic syndrome is characterized by a cluster of cardiovascular risk factors including increased central abdominal obesity, elevated triglycerides, reduced high-density lipoprotein, high blood pressure, increased fasting glucose, and hyperinsulinemia. These factors increase the risk of cardiovascular disease (CVD) and/or type 2 diabetes. Low T is associated with metabolic syndrome, and with increased deposition of visceral fat, which serves as an endocrine organ, producing inflammatory cytokines and thus promoting endothelial dysfunction and vascular disease.
• Low T is strongly associated with type 2 diabetes (NIDDM) and insulin resistance. Hypogonadal men are at higher risk for NIDDM. TRT in hypogonadal men improves insulin sensitivity, fasting glucose, and HbA1c levels.

Does TRT increase the risk of developing prostate cancer?

We don’t know.

The data are far from conclusive, as there are no high-quality studies (i.e. placebo-controlled, double-blind randomized trials) that have been reported on the long-term use of TRT.  Short-term (<3 years) use of TRT does not seem to increase the risk of developing prostate cancer among men who were studied during this short time interval. Most studies report that short-term TRT does not lead to a rise in PSA levels or in prostate size, which suggests minimal-to-no effects on stimulating prostate cell growth.

The concern is that long-term administration of TRT may increase a man’s risk of developing prostate cancer. This is a lesson that we learned after long-term administration of estrogen and progestin replacement therapy to help women with post-menopausal symptoms (5+ years of estrogen and progestin therapy increased the risk of developing breast cancer by 25% over placebo). It took over 8 years of follow-up to identify this increased risk.

Recent data suggest that men with low T levels may be more likely to be diagnosed with aggressive prostate cancer pathology (i.e. higher Gleason scores, greater incidence of seminal vesicle invasion, etc.) than men with higher T levels. Regarding these findings, one of the most well-respected researchers on this subject (Abraham Morgentaler, MD, Beth Israel Deaconess Medical Center, Boston MA) states, in a recent editorial, “Finally, after 7 decades of circumstantial evidence pointing us in the wrong direction, perhaps it is time to consider the once unthinkable: a T therapy trial of sufficient size and duration to determine whether normalization of serum T in older men may reduce the risk of PCa, particularly high-risk PCa.”

For the time being, recommending TRT in symptomatic hypogonadal men with no evidence of prostate cancer seems reasonable with the caveat that they completely understand the limitations of the available data.

Read a great review on this topic: “Testosterone Replacement Therapy and Prostate Risks: Where’s The Beef?”

Does TRT fuel the growth or recurrence of prostate cancer?

We don’t know.

Most prostate cancer cells possess receptors that are able to be stimulated by testosterone to grow and divide.  Therefore, giving TRT to a man with active, untreated prostate cancer has been considered analogous to throwing fuel on the fire. Due to this potential concern and the policy of “do no harm”, many physicians do not recommend TRT for men with a history of prostate cancer.  However, the data supporting this policy has been called into question by Dr. Morgentaler and others.

Data regarding men who have been previously treated for prostate cancer:

In a meta-analysis (by Dr. Morgantaler) of 6 uncontrolled studies that included data on the risk of prostate cancer recurrence in men (n=111) who received TRT after treatment for prostate cancer (i.e. radical prostatectomy, external beam radiation therapy or brachytherapy), the author found that the risk of a biochemical recurrence was only 1.8%. (Morgentaler A., J Urol, 2009)

In a separate meta-analysis (by Mohit Khera, M.D., M.B.A., M.P.H., Baylor College of Medicine, Houston, TX), the author reviewed all publications, to date, looking at the effects of TRT on men who were previously treated for prostate cancer. Dr. Khera found that among the 292 men treated with TRT in these studies, their risk of prostate cancer recurrence was less than 1%. (Khera M., Curr Urol Rep, 2010)

Data among men with prostate cancer that has not been treated:

In a small study, Dr. Morgentaler and co-authors examined the effects of TRT in 13 men with untreated prostate cancer undergoing active surveillance. The men had a mean age of 59, mean PSA value of 5.5 ng/mL, mean testosterone concentration of 238 ng/mL, and all but one had a biopsy Gleason score of 6 (one patient with Gleason 7). After a median treatment duration of 2.5 years, the group’s testosterone values averaged 664 ng/dL (P<0.001). Mean PSA level declined to 3.6 ng/mL, which did not differ significantly from baseline. Prostate volume also did not change. The men had an average of two prostate biopsies during follow-up, and 54% of specimens had no evidence of cancer. The limitations of the study included its small size, retrospective design, inclusion of some men who had prostate cancer diagnosed after the start of testosterone therapy, and lack of generalizability to those with higher grade or higher volume disease.

Dr. Morgentaler writes: “The prohibition against the use of testosterone therapy in men with a history of prostate cancer is based on a model that assumes the androgen sensitivity of prostate cancer extends throughout the range of testosterone concentrations. Although it is clear that prostate cancer is exquisitely sensitive to changes in serum testosterone at low concentrations, there is considerable evidence that prostate cancer growth becomes androgen indifferent at higher concentrations. The most likely mechanism for this loss of androgen sensitivity at higher testosterone concentrations is the finite capacity of the androgen receptor to bind androgen. This saturation model explains why serum testosterone appears unrelated to prostate cancer risk in the general population and why testosterone administration in men with metastatic prostate cancer causes rapid progression in castrated but not hormonally intact men. Worrisome features of prostate cancer such as high Gleason score, extracapsular disease and biochemical recurrence after surgery have been reported in association with low but not high testosterone…Anecdotal evidence suggests that testosterone therapy does not necessarily cause increased prostate specific antigen even in men with untreated prostate cancer. In terms of giving TRT to men with a history of prostate cancer, the main impediment at this point is that there still are no large, long-term studies that can give us the bounds of safety data on this.”

Dr. Khera writes: “Historically, testosterone supplementation has been avoided in men with a history of prostate cancer because of concern about prostate cancer progression or recurrence. However, recently published data suggest that this concern may not be well founded. The recurring presence of prostate-specific antigen in men with hypogonadism being treated with testosterone after prostatectomy is far less than the expected natural recurrence rate of the disease. There are many theories (including the prostate saturation theory) that may help us understand why testosterone may be safely administered in men with hypogonadism after surgical treatment of prostate cancer. Finally, because patients with hypogonadism already may be at a significant disadvantage in recovering their erectile function after prostatectomy, they perhaps should receive special consideration as candidates for androgen replacement therapy.”

Pre-TRT assessments and monitoring during TRT:

Experts recommend:

• A baseline digital rectal examination (DRE) and PSA should be checked before starting a patient on TRT, and a PSA should be checked again within 3-6 months. The PSA and DRE should then be monitored every 6 months while on TRT.
• The American Society of Andrology recommends periodic monitoring of men receiving testosterone replacement therapy. Subject to individual clinical response, evaluation is recommended at 3-6 months after initiation of therapy, and then yearly. A physical examination, including DRE, a prostate- related symptom assessment, PSA level and hematocrit should be performed at 3,6, and 12 months and then annually. TRT should be altered or ended if the hematocrit exceeds 52%.
• Read an evidence-based review: December 2010,The Journal of Family Practice, “How should we monitor men receiving testosterone replacement therapy?”
• Typically, a PSA velocity > 0.75 ng/ml/year (regardless of the baseline PSA) or a nodule on DRE during testosterone replacement therapy should prompt further evaluation by a urologist and possible prostate biopsy. However, the optimal frequency of monitoring and cutoff points, both for referral to urology and prostate biopsy, remain somewhat controversial. This ambiguity is reflected in the various PSA cutoff points that have been suggested, ranging from > 0.4 to > 1.5 ng/ml/year, depending on how many years of observation are considered.

How is TRT administered?

Risks and side effects of TRT:

In general, hormone replacement therapy is safe. It is occasionally associated with the following side effects:

• acne or oily skin
• mild fluid retention
• prostate enlargement
• breast enlargement
• worsening of sleep apnea
• decreased testicular size

Laboratory abnormalities that can occur with hormone replacement include:

• changes in cholesterol concentrations
• increase in red cell count
• decrease in sperm count, producing infertility (especially in younger men)

If you are taking TRT, regular follow-up appointments with your physician are important.

Contraindications to therapy include active prostate cancer, breast cancer, untreated sleep apnea, and untreated and/or severe congestive heart failure.

The bottomline:

For some patients, the quality of life improvement on TRT is worth more to them than the likely small risk of prostate cancer progression. I feel that it is very reasonable to offer patients, who are symptomatic from their hypogonadal state (with or without a prior history of prostate cancer), TRT as long as:

1. they are not actively receiving androgen deprivation therapy for prostate cancer
2. they do not have advanced or progressing prostate cancer
3. they do not have a history of breast cancer
4. their post-treatment PSA has been stable for at 6 months after treatment of their prostate cancer
5. they understand the limitations of the available data (i.e. short-term TRT administration, limited follow-up, lack of randomized controlled trials)
6. they recognize that there are potential risks of TRT stimulating prostate cancer growth and progression
7. they agree to close follow-up

In a fascinating and (as always) thought-provoking Ted Kaptchuck (Harvard Medical School) study, 39 asthma patients were randomized to one of four groups and instructed to discontinue their asthma medications:

• albuterol inhaler (a common asthma medication) given at the time of the asthma symptoms
• placebo inhaler (inactive medication) given at the time of the asthma symptoms
• placebo acupuncture (fake needle that feels like it penetrates the skin but does not) given at the time of the asthma symptoms
• no treatment

In all 4 groups, the patients had their lung function tested every 20 minutes for two hours.

Results:

As expected, treatment with the albuterol inhaler improved lung function by 20%. The placebo inhaler and placebo acupuncture patients also had a modest improvement in their lung function (7%). Their was no improvement with the no treatment group.

When the patients were asked  if they felt better after treatment, the same percentage of patients from the 3 intervention groups (albuterol inhaler, placebo inhaler and placebo acupuncture) stated that they felt better (approximately 50%). Only 21% of the patients in the no treatment group felt better.

The bottom-line:

A proven medical therapy (i.e. albuterol) is more effective than placebo when measuring the physiologic responses to the interventions, but there was no measurable difference in patient perception between active treatment (albuterol) and placebo…simply providing a therapy that was perceived to be effective had a strong therapeutic response that was the same among the intervention groups.

Point 1: As medical practitioners, we should never withhold safe and effective therapies from any patient who needs them.

Point 2:  Placebo therapies do not have a defined physiologic effect, yet the simple act of providing care that is perceived as effective has legitimate and powerful ‘mind-body’ effects in relieving symptoms and disease…do no harm and relieve illness and/or suffering are the primary goals of the practice of medicine.

Conventional and non-conventional medical practitioners may not recognize that a significant component of their patients’ response to their interventions is from unintended, but active, placebo effects (i.e. prescribing sub-therapeutic doses of medications, practitioners’ appearance and manner is convincing to the patient, demonstrating attention and compassion to their patients, prescribing pharmacologically inactive supplements, etc.).

The beneficial effects of placebo on health and well-being of our patients provides further evidence of the power of the minds’ ability to heal the body and relieve its’ suffering.

As an integrative oncologist, I find placebo research very exciting as it will eventually lead to a better understanding of the complexities of mind-body physiology with the goal of helping our patients harness this innate self-healing power.

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From time to time, we need to take a step back and simply review the overall concept of integrative oncology. 

What Is Integrative Oncology?

**(psst…nevermind the term “integrative medicine”…it’s called practicing quality “medicine”)**

Integrative oncology is a ‘whole person care’ approach to cancer care that takes into account each individual’s unique circumstances to customize treatment programs. It combines the appropriate conventionalcancer treatments (for example: surgery, radiation, chemotherapy), complementary therapies (for example: acupuncture, massage, meditation) and behavioral/lifestyle education to help patients improve their quality of life (psychological, spiritual and physical), cancer outcomes and overall health.

Integrative oncology is not an “alternative” approach to cancer care. Increasingly, prestigious academic cancer centers (for example: Harvard, Memorial Sloan Kettering, MD Anderson, Duke, UCSF) are incorporating integrative oncology within their practice of taking care of patients living with and beyond cancer.

The Society for Integrative Oncology (founded in 2003) is an non-profit, multi-disciplinary, international “organization of professionals dedicated to studying and facilitating cancer treatment and the recovery process through the use of integrated complementary therapeutic options.” **As a plug (FYI: I’m a board member of the SIO), the upcoming annual conference (November 10-12, 2011) will feature the Director of the U.S. National Institutes of Health, Francis S. Collins, MD PhD, as the keynote lecturer.**

Integrative Oncology Is Not About Treating Cancer With Alternative Therapies

As an integrative oncologist, I commonly see patients who are interested in learning about what “other” things they can do to improve their chances of beating cancer. The first thing I always clarify about integrative oncology is that it is not about treating the cancer with “alternative” therapies. Alternative therapies are therapies that have not been supported by quality research (i.e. ‘not evidence-based’) and are used ‘in place’ of proven therapies, such as chemotherapy and surgery. Integrative oncologists do not support the use of alternative therapies in the place of proven therapies.

In contrast, we completely support the use of “complementary therapies” (i.e. acupuncture, massage, yoga, natural botanical remedies, etc.) and behavior/lifestyle counseling (i.e. dietary, fitness, stress reduction, etc.), which have been demonstrated to be safe and effective in helping our patients better tolerate the side effects of conventional treatment and the symptoms of the cancer itself.  Furthermore, the beneficial effects of these therapies (i.e. botanical medicinals) and lifestyle changes (increasing physical activity, reducing stress, etc.) on inhibiting cancer development and progression is increasingly evident (stay up to date on the latest studies on the IOE blog, website and Facebook Fan Page).

Integrative oncology recognizes the fact that when our patients are able to receive the entire prescribed course of cancer treatment they will achieve the best results.

What Is An Integrative Oncology Consultation?

During an integrative oncology encounter, in addition to the traditional medical history and physical, many other subjects are addressed that are very important to the holistic (whole) approach to cancer care. We spend time reviewing our patient’s diet, physical activity and psychological stress. These factors have been implicated in the development and progression of many cancers. Recent studies have suggested that when these lifestyle factors are optimized, significant improvements in outcomes have been reported (such as: improved survival, decreased risk of cancer recurrence, reduced symptoms and side effects.)

Optimizing nutrition and diet is a key component in integrative oncology, and is one of the many topics discussed during these encounters. Increasingly, studies suggest that by eating a diet rich in foods containing a variety of natural anticancer compounds, as well as limiting consumption of specific types of fats and carbohydrates, an individual is creating an environment within their body that is not conducive to cancer development and growth. There are literally thousands of natural compounds that have been discovered in various plants and other foods that, when taken for prolonged periods of time, may reduce the risk of cancer development and progression. Many of these natural products function in a similar manner as commonly prescribed drugs, and yet have a significantly lower risk of side effects. Consuming these substances as part of a whole foods diet is the most favorable way of obtaining their beneficial effects. **It is very important to inform your oncologist and surgeons about any vitamins or supplements you are taking, as these may alter the effectiveness of certain treatments, increase their toxicity or lead to complications (such as bleeding.) Learn more about Anti-Cancer Nutrition, Dietary Tips and Meals.

Another key component of integrative oncology is stress reduction. It is quite common to come down with a cold shortly after periods of high stress. Scientists believe that this is likely a result of naturally occurring stress hormones (like cortisol and epinephrine) causing a decrease in the strength of the immune system. Substantial evidence suggests that exposure to long periods of stress increases rates of cancer development and growth. A recent study reported that a group of breast cancer survivors who were taught stress reduction techniques had a lower risk of cancer recurrence and improved survival compared to survivors who did not receive this teaching.  Regardless of whether stress reduction techniques are able to improve cancer outcomes, there is no doubt that they can greatly improve quality of life. Stress reduction techniques can involve any of variety of effective options, such as massage therapy, meditation, guided imagery, yoga, cognitive based therapies, prayer, walking on the beach, and many others. Learn more about Stress Reduction.

Following a diagnosis of cancer, it is not uncommon for patients to reduce their level of physical activity as a result of fatigue, discomfort or other side effects of treatment. Unfortunately, decreasing physical activity may actually increase the risk of cancer recurrence or growth. Physical activity has many positive effects on the mind and body (such as: a reduction in tumor growth factors, estrogen and free radical production; increases in immune function, improvements in sleep and fatigue, and reduction in anxiety and depression.)  If you choose to work with a fitness instructor or physical therapist, be sure to select one who is experienced in working with cancer patients. There are many forms of physical activity that can have great beneficial effects for individuals living with and beyond cancer (such as: yoga, tai chi, walking.) **It is important to discuss any changes in physical activity and exercise with your oncologist. Learn more about Physical Activity and Exercise.

In Summary

The integration of various CAM therapies, whole health systems (such as: traditional Chinese medicine and Ayurvedic medicine), conventional cancer treatments and behavioral/lifestyle changes is the realm of integrative oncology.

Navigating the waters of this complex array of options can be confusing. A visit to an integrative oncologist may be a helpful way to start this journey.

Link to my original article (Healthy Times Newspaper)

Where Can You Get An Integrative Oncology Approach To Your Care?

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Radiation therapy has been used for the treatment of skin cancers since the early 1900′s and continues to be one of the best therapies available. Significant advances have revolutionized radiation therapy technologies, increasing treatment precision and reducing side effects.

Although surgery is a very effective treatment, there are occasional risks:

• impaired wound healing (particularly in those with diabetes, the elderly, peripheral vascular disease, smokers)
• post-operative bleeding
• post-operative wound infections
• surgical scars
• functional and/or cosmetic deformities (in some circumstances skin grafts/flaps may be required to cover the surgical defect)

How effective is radiation therapy?

Most studies report eradication rates of 90-98% with excellent cosmetic and functional results in the majority of basal and squamous cell carcinomas of the skin.

The images below demonstrate the excellent results that are typical after radiation treatment.

• Patient 1: Face/ear invasive squamous cell carcinoma treated with radiation therapy. Had surgery been the treatment offered, this patient would likely have required extensive surgery and a skin graft or flap to cover the surgical defect. (Left image: before radiation therapy; Right image: after radiation therapy)

• Patient 2: Eyelid skin cancer treated with radiation therapy. Surgery would have led to a cosmetic/functional defect in the lower eyelid. (Left image: before radiation therapy; Right image: after radiation therapy)

• Patient 3: Cheek skin cancer treated with radiation therapy. (Left image: before radiation therapy; Right image: after radiation therapy)

There are a variety of risk factors that may reduce the efficacy of radiation therapy (i.e. larger tumor size, aggressive skin cancer subtype, recurrent skin cancers, invasion into nerves, vessels or underlying muscle or bone). Based on these and other factors, appropriate treatment recommendations will be made.

How is radiation therapy administered?

There are a variety of radiation therapy technologies that may be used to precisely deliver a superficial form of radiation (i.e. electrons, x-rays, gamma-rays) that penetrates only a short distance below the skin surface.

We often include a small (i.e. 5-10 mm) margin of skin around the cancer within the radiation treatment area to make sure that we don’t inadvertently miss any tumor cells that may be growing microscopically into the adjacent tissues.

The following modalities are commonly used:

• External beam radiation therapy (i.e. superficial x-rays, electron beam therapy)
• Brachytherapy (i.e. read about “HDR brachytherapy”, below)

What is the length of the treatment course?

Treatments typically take less than 5 minutes to deliver, each day. Depending on different factors, your physician will recommend the appropriate treatment course (duration range: 2-7 weeks). Most treatments are delivered 5-days per week (monday-friday), although some treatment courses may only require 2-3 days per week.

One of the more convenient treatment options is a twice-a-week treatment (5-minutes each session) for 3-weeks, using a technology called “high-dose rate brachytherapy” (HDR). The ideal candidate for HDR treatment is anyone with a basal or squamous cell skin cancer that less than 1-inch (2.5 cm) in diameter and less than 5 mm in depth. The image below demonstrates an example of how the HDR treatment applicator, which holds a small radioactive seed, is gently placed over the lesion to be treated (top of hand, in this case).

Who is a candidate for radiation therapy?

• Anyone with a basal or squamous cell skin cancer who has not been previously treated with radiation to the same area as the new cancer is a good candidate, or
• Anyone who does not want surgery, or
• Anyone who has healing difficulties (i.e. diabetics, elderly) or bleeding problems (including those who need to remain on blood thinning medications), or
• Anyone who has multiple skin cancers or larger skin cancers in one or more regions on the body (i.e. scalp, face, extremities, trunk, torso), or
• Anyone who has been told that surgical removal of the cancer may require plastic surgery (i.e. skin graft, flap) to cover the surgical defect,
• Anyone with skin cancers in cosmetically and functionally challenging areas (i.e. eyelids, nose, ears, lips, hands)
• Other skin cancers that can also be treated with radiation include: melanoma (reserved for patients who are too ill or refuse surgery), Merkel cell carcinoma, sweat gland tumors

What are the side effects of this treatment?

You will not feel anything during your radiation treatments- they are painless. For the first 1-2 weeks of treatment, most patients do not notice any symptoms or side effects.

After 2-3 week, the most common side effects are skin redness, peeling  and mild-to-moderate skin sensitivity in the area of the cancer.  In the vast majority of patients, these symptoms will resolve within a few weeks after the treatment course is over.

Months-to-years after the treatment, the radiated skin may develop a slightly lighter or darker appearance, although most patients have no obvious skin coloration changes. Additionally, the radiated skin may become slightly thicker or firmer over time.

Although this is a very rare risk, cancer can develop in the radiated tissues years after treatment. The risk is 1 in 1,000 people who receive radiation.

The bottomline:

Radiation therapy is an excellent treatment for the two most common skin cancers (basal cell and squamous cell carcinomas), however it may or may not be appropriate for you. It is important to discuss this with your physicians.

Start by asking your dermatologist if they believe that radiation therapy is a reasonable option for you, as there are many treatment options available that I did not discuss in the blog post.

Learn more about skin cancers here. (American Academy of Dermatology)

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Read more about acupuncture (National Center for Complementary and Alternative Medicine)

There are multiple methods that can be used to stimulate acupuncture points (i.e. needles, acupressure, massage, heat, cupping, electrical stimulation, lasers, etc.) Because I am a ‘tech-geek’, I chose to focus of this blog entry on the use of lasers in acupuncture.

Conditions treated with laser acupuncture:

Recently published studies have demonstrated that certain low-energy lasers (also called “cold” or “low-level light therapy” lasers or “LLLT”) appear to be an effective, noninvasive, painless alternative (to needles) for stimulating acupuncture points.

• Reduce fatigue
• Enhance relaxation
• Reduce insomnia
• Reduce asthma symptoms
• Reduce pain
• Reduce inflammation
• Improve mild–moderate depression
• Reduce postoperative nausea and vomiting
• Improve allergic rhinitis
• Reduce postmastectomy limb lymphedema
• Reduce chronic prostatitis symptoms
• Smoking cessation

Cold laser acupuncture is an appealing therapeutic option in situations of immunocompromised states, bleeding abnormalities, and needle phobia. For these reasons, many acupuncturists and physical therapists have incorporated laser acupuncture and cold laser therapy in their practices.

Links for laser therapy research:

Research articles on laser therapy (MEDLINE)

Research articles organized by topic

Fantastic blog on low level light/cold laser therapy (THOR Photomedicine, Ltd)…great website too!

Can you feel the acupuncture laser light?

No. These are low-energy lasers that do not transfer sufficiently high energy to cause a perceptible change in temperature within the tissues.

Is laser acupuncture safe?

Laser acupuncture is safe, but eye protection is recommended. The majority of the lasers used for laser acupuncture are infrared, as this wavelength has the deepest penetration within the tissues (up to 2-3 inches or 60 mm deep) and can easily reach the depths of most acupuncture points.  Infrared light is mainly outside of the visible spectrum, so it can not be seen. The normal neurologic response to strong light is to blink or squint as a built-in protective mechanism to prevent retinal injury. Since infrared light can not be seen, there is a greater risk of retinal injury. It is therefore recommended that eye protection (filtered googles) should be used during laser acupuncture treatments to prevent unintended eye injury.

How does laser light stimulate acupuncture points?

Our understanding of exactly how laser light stimulates acupuncture points is not well understood. What we do know is that, like acupuncture needles, cold laser light can cause a host of direct and indirect physiological changes (also known as “photobiomodulation”) both in the tissues in which they are pointed and systemically. There is an extensive body of research reporting on the photobiomodulation effects with cold laser light (examples):

• Enhanced wound healing (ie, increased tensile strength,reduced wound healing time, reduced inflammatory cell migration, increased mitochondrial activity, increased fibroblast cell migration, increased angiogenesis, reduced edema)
• Enhanced nerve regeneration (ie, thicker nerve fibers, more regular myelin layers, clearer nodes of Ranvier with absence of short nodes)
• Increased osteoblast activity and increased osteochondral wound healing
• Increased cellular metabolism (ie, increased adenosine triphosphate production, increased mitochondrial activity)
• Increased blood perfusion (ie, increased nitric oxide synthase)
• Increased angiogenesis (ie, increased vascular endothelial growth factor, endothelial cell proliferation)
• Reduced inflammation (ie, reduced cyclooxygenase-2 messenger ribonucleic acid, reduced myeloperoxide activity, reduced nuclear factor k-B activation, reduced reactive oxygen species)
• Non–opioid-dependent mechanisms responsible for pain control (ie, pain control involves hyperalgesic mediators instead of peripheral opioid receptors)

Is laser acupuncture just another placebo treatment?

Studies have been conducted to examine this question, and it appears that laser acupuncture causes real and measurable effects within the brain.

Among the most convincing studies are those that employ functional magnetic resonance imagine (“fMRI”) to identify and quantify actual changes in brain activity in response to stimuli.  To determine if the effects of cold laser stimulation on acupuncture points are detected and processed by the brain (real effect) or not detected by the brain (placebo response), investigators have conducted double-blinded randomized studies using fMRI to examine the brain activity differences in which inactive (fake/placebo lasers) and active lasers are tested on the same acupuncture point.

Since the cold laser light is neither visible to the study subjects (dark, black-out goggles are placed on the patient) nor able to be felt (no heat or energy is perceptible with low-energy lasers), they have no way of knowing (unlike with a needle) if they are receiving laser acupuncture.

The investigators reported that significant brain activity changes were only noted among the subjects who received the laser acupuncture treatments, not in those who received the placebo laser ‘treatments’. This data strongly suggests that laser acupuncture exerts true physiologic effects that cannot be accounted for by a “placebo” response.

Can you teach yourself laser acupuncture?

Absolutely (caveat: read my “final thoughts” below). Unlike with acupuncture needles, laser acupuncture requires no more technical skill than using a laser pointer. Most people can easily learn the point locations of some of the more commonly used acupressure or acupuncture points (located in the same positions).

My favorite treatment is called the “Four Gates.” This is a simple 4-point treatment that is very frequently used to help relieve stress, anxiousness and pain (particularly headaches). There are 4-points involved in this treatment:

• “Large Intestine 4″ on right and left hands (on the top of the hand in the web between the thumb and index finger- it is a pressure point, so it is simple to locate)
• “Liver 3″ on the right and left feet (on the top of the feet between the 1st and 2nd toe, slide your finger up into the depression just distal to the junction of the first and second metatarsal bones)

The following useful links make it easy to find some of these points:

Yin Yang House

PointFinder Acupressure Guide Online

AcuFinder

How long are each treatments?

That depends on the laser. Higher energy lasers more quickly deliver sufficient dose to the points than lower energy lasers. Typically, treatments take approximately 5-10 minutes to complete. Each acupuncture laser will come with instructions on how long the treatments should take per point.

Where can I buy acupuncture lasers?

There are many devices available on the market. A quick search on the internet will point you in the right direction. These are not your everyday ‘red dot’ (Helium-Neon or He-Ne) laser pointers. The wavelengths of acupuncture and cold laser therapy devices enable much deeper light penetration (up to 60 mm penetration) into the tissues than the He-Ne lasers (minimal penetration beyond 2 mm).Personal acupuncture lasers cost between $100 to well-over $1000 (professional units are more costly). I don’t endorse one product or manufacturer over another. Make sure to include the purchase of laser eye goggles with your order.

Final Thoughts:

Do not take away from this article that acupuncture is a simplistic cookbook of points. Acupuncture is only one aspect of an elegant and complex system of traditional Chinese medicine (TCM), a field that incorporates many therapeutic and preventative modalities (i.e. needles, herbal therapy, moxibustion, cupping, massage, physical activity, dietary recommendations, etc.) and takes many years of training to master.

TCM practitioners select combinations of acupuncture points based on a sophisticated diagnostic process that leads them to an understanding of each individual’s particular diagnosis. For this reason, if treating yourself with acupressure or laser acupuncture does not yield the desired results…get a referral to see a licensed acupuncturist (i.e. L.Ac.). I assure you, the results will be more impressive than you can get on your own. If you own an acupuncture laser, I recommend that you ask your acupuncturist to help you use your laser more effectively. They can teach you to find the precise locations of some of the more accessible to reach acupuncture points (i.e. those on the front or sides of your extremities, abdomen or trunk) that are specific to your problems.

More information on acupuncture training and certification here. (National Certification Commission for Acupuncture and Oriental Medicine)

Learn about “medical acupuncture” (American Academy of Medical Acupuncture)

Read an introduction on TCM (National Center for Complementary and Alternative Medicine)

Here’s a link to a published study I conducted on the use of laser acupuncture in the oncology clinic.

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A practice changing study, published in February 2011, in the Journal of the American Medical Association, reported the results of an important randomized trial of women with breast cancer who had metastatic involvement of their axillary sentinel lymph nodes (SLN).  A procedure call a “sentinel lymph node dissection” (SLND) enables the surgeon to examine whether cancer has spread from the tumor to the lymph nodes (in particular, to the “sentinel lymph node” or SLN). Patients whose SLNs are free of cancer do not need to undergo a more extensive lymph node surgery called a “completion axillary lymph node dissection” (ALND), thereby significantly decreasing the risk of developing complications (i.e. lymphedema, infections, shoulder dysfunction, pain syndromes, etc.)

Read more about axillary lymph node surgery here.

Prior to the this study, the standard of care for those patients whose SLNs were involved with cancer (“lymph node positive”) has been to perform an ALND to remove the remaining axillary lymph nodes. For years, surgeons and oncologists believed that by removing the remaining lymph nodes with an ALND in patients with a positive SLN, they would reduce the risk of cancer recurrence in the axilla and improve survival.

This study will put end to the ALND in many patients who have a positive SLN (as long as they meet the eligibility criteria below).

Study summary:

Randomization groups: The investigators from 115 sites (American College of Surgeons Oncology Group) randomized two groups of women with metastases detected at the time of SLND to either undergo ALND (445 patients) or no further axillary surgery (446 patients).

Eligibility criteria: Eligible women had invasive breast tumors <5 cm and one or two positive SLNs. All patients received whole-breast radiotherapy following breast-conserving surgery and SLND; 96% received adjuvant systemic therapy.

The following patients were not eligible for this study (and should therefore be recommended to undergo a completion ALND):

• palpable nodal disease at presentation
• patients who received preoperative chemotherapy
• patients who undergo mastectomies
• patients who do not receive postoperative radiotherapy or partial-breast radiotherapy

Results:

• Among patients in the ALND group, 27% were found to have additional positive nodes.
• No difference was found between the two groups in survival or recurrence rates (At median follow-up of 6.3 years):
  • 5-year overall survival was 92% with ALND and 93% with SLND alone (no statistical difference)
  • 5-year disease-free survival was 82% with ALND and 84% with SLND alone (no statistical difference)

The bottomline: Even though there was a 27% chance of finding additional metastatic axillary lymph nodes in the patients who underwent SLND+ALND, the OMISSION of ALND had NO EFFECT on recurrence or survival rates.

As a result of this study, many academic cancer centers in the U.S. are no longer recommending ALND in patients with positive SLNs who will be treated with subsequent adjuvant systemic therapies and whole-breast radiotherapy (learn more about “adjuvant” treatment for breast cancer here). This change in surgical management will certainly further decrease the risk of development of complications of ALND and lead to significant improvements in the lives of these patients.

If you want to learn more about lymphedema, check out my blog entry and review article (published in the American Cancer Society’s journal CA, A Cancer Journal for Clinicians)

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• a 61% increased risk of prostate cancer recurrence after treatment, and
• a 61% increased risk of dying from their prostate cancer

Not surprisingly, the smokers also had a much higher rate of dying from cardiovascular disease: 213% greater risk!

Additionally, their was a dose-response effect that demonstrated that those men who smoked the most also had the worst outcomes:

• Current smokers of 40 or more pack-years (a “pack-year” is defined as smoking one pack per day for one year…40 pack-years means you smoked one pack per day for 40 years) versus never smokers had an 82% increased risk of dying from their prostate cancer
• Compared with current smokers, those who had quit smoking for 10 or more years or who have quit for less than 10 years but smoked less than 20 pack-years had the same risk of dying from prostate cancer as never smokers.

This is not the first study to demonstrate worse outcomes in patients who continue to smoke, but the is the first rigorous analysis to show this association in prostate cancer. Other cancers that seem to be associated with worse outcomes in smokers include: lung, cervical, breast, and head & neck cancers

Partly explaining the increased aggressiveness of cancers in smokers, may be a function of the unhealthy lifestyle factors common among smokers (i.e. diets higher in saturated fats, refined flours and simple sugars, low levels of physical activity, higher stress levels, insufficient sleep, etc.) Read more about the “anti-cancer” lifestyle on the IOE website.

Other studies have reported that toxic compounds in tobacco smoke, produced through the combustion process, directly and indirectly increase the aggressiveness of cancer cells (i.e. increasing tumor growth rate, increasing testosterone production, increasing systemic inflammation, decreasing tumor cell sensitivity to radiation therapy, etc.).

The bottomline: If you have cancer, DON’T SMOKE!!  By quiting now, you will increase your odds of preventing cancer recurrence and progression and from dying from your cancer and cardiovascular disease.

There are many options available to help you kick this addictive habit:

• go ‘cold turkey’ (the hardest option…although your diagnosis of cancer may help motivate you)
• nicotine patches or gum
• prescription medications that help decrease the urge to smoke
• join a smoking cessation program (most effective option)
• try acupuncture
• electronic cigarettes and vaporizers, etc…

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Simply put, PBT is the most advanced radiation therapy technique available. This star wars-like technology has been used in the treatment of malignant and benign tumors since the 1950′s. As of 2011, over 73,000 patients have been treated at proton beam treatment centers around the world. The number of these centers is growing quickly. Since 1990, when the first hospital-based proton facility opened (Loma Linda University, California), there are now 37 proton beam therapy centers located in Canada, China, England, France, Germany, Italy, Japan, Korea, Poland, Russia, South Africa, Sweden, Switzerland, and USA…and many more are in development and under construction.

In the U.S., the following cancer programs have (or have announced that they will soon have) PBT available for their patients:

• James M. Slater, M.D. Proton Treatment and Research Center at Loma Linda University Medical Center
• The University of Florida Proton Therapy Institute
• M.D. Anderson Cancer Center’s Proton Center, Houston
• ProCure Proton Therapy Center, Oklahoma City
• The Roberts Proton Therapy Center at University of PA Health System
• Hampton University Proton Therapy Institute
• CDH Proton Center, A ProCure Center,Chicago Area, Illinois
• Indiana University Health Proton Therapy

• Francis H. Burr Proton Center at Mass. General Hospital
• ProCure Proton Therapy Center in partnership with Princeton Radiation Oncology Group and CentraState Healthcare System, Somerset, N.J.
• ProCure Proton Therapy Center in partnership with the Seattle Cancer Care Alliance, Seattle, WA
• The McLaren Proton Therapy Center, Flint, Michigan
• The Proton Therapy Center, Knoxville, in partnership with the University of Tennessee Medical Center
• Proton Institute of New York (a consortium, managed by 21st Century Oncology, which includes: Memorial Sloan-Kettering Cancer Center, Beth Israel Medical Center, NYU Langone Medical Center, Montefiore Medical Center and Mount Sinai Medical Center)
• Mayo Clinic Proton Beam Therapy Program with locations in Rochester, Minnesota and Phoenix, Arizona
• University Hospitals, Seidman Cancer Center, Cleveland, Ohio (PBT technology awaiting FDA approval)
• Barnes Jewish Hospital in St. Louis, Missouri (PBT technology awaiting FDA approval)
• Tufts University School of Medicine, Boston, Massachusetts (PBT technology awaiting FDA approval)
• Robert Wood Johnson University Hospital, New Jersey (PBT technology awaiting FDA approval)

What makes PBT so unique?

All external beam radiation therapy (EBRT) technologies use shaped beams of high-energy radiation to target and kill tumors by either causing irreparable DNA damage within the cancer cells or by disrupting the vascular supply to the growing tumor. The most common radiation technique uses high-energy x-rays, which deposits radiation dose in a path from body surface to the tumor. In most cases, the x-ray beam will continue to travel through the intended target as it deposits the remaining radiation energy in the tissues beyond the tumor.

In contrast to conventional x-ray based EBRT, PBT does not damage healthy tissues beyond the tumor as proton beams stop precisely at the back edge of the tumor due to a unique dose deposition characteristic of protons and other particle-based therapies, called the Bragg peak.  X-ray beams, do not deposit their dose at a sharply defined depth in tissue (Bragg peak), so they pass through the tumor without stopping and continue to deposit ionizing radiation into healthy tissues and organs beyond the intended target.  Dose deposition beyond the intended target is called “exit dose” and is not desired. Unlike x-ray based EBRT, PBT does not exhibit any significant exit dose.

A proton beam is generated through 3 steps: 1) through hydrolysis hydrogen atoms (protons) are separated from water molecules, 2) protons are then injected into a cyclotron (a large, 90-200 ton, electromagnetic device) and 3) the protons are accelerated between two electrodes to nearly 2/3 the speed of light.

These high-energy protons are then guided into the treatment rooms through a series of electromagnets. The beams are then shaped and focused to customize the coverage of the target (i.e. tumor) while minimizing radiation dose to the surrounding tissues.

The beam can be rotated around the patient by rotating the gantry (the cylindrical treatment head which delivers the beam into the room) or by adjusting the patient’s position (enabling X-Y-Z movements and pitch, yaw and roll) with a robotic-assisted table-top.

Proton treatment centers are BIG (often 3+ stories high to accommodate the large cylindrical gantries and 4+ treatment rooms) and EXPENSIVE (approximately $200 million dollars). Smaller proton treatment centers (1-2 treatment rooms) with more compact cyclotrons (90 tons versus 200 tons) will be the next evolutionary step for the product developers (expected in the next 5 years). The cost of these smaller facilities will be in the range of $20-40 million dollars.

Complications and side effects rarely occur in unirradiated tissues:

Radiation-related complications rarely occur in unirradiated tissues/organs, which is why radiation oncologists take great care in minimizing high-dose radiation to non-target tissues. (The image below demonstrates the substantial differences in the amount of healthy brain tissue that is exposed to the risks of ionizing radiation: Left=PBT, Right=X-rays)

However, even low radiation doses can cause problems in irradiated tissues years-to-decades after completing a course of treatment. The images below shows a child who is receiving treatment for a tumor that can spread to the spinal cord tissues (medulloblastoma). The target tissues in this case are the brain and spinal tissues. In the upper image (x-rays), not only is the target tissue being treated but so is the healthy tissues in the chest (lungs, heart, esophagus), abdomen (stomach, liver, kidneys, bowel) and pelvis (bladder, rectum, reproductive organs). In the lower image (PBT), only the target tissues are being treated–sparing the child from any complications or side effects that could develop in those tissues.

The rarest (and most concerning) complication is the development of a radiation-induced cancer, but a host of other more common complications can also occur: cataracts, coronary artery disease, fibrosis and stenosis of tissues, bone growth impairment in growing children, hormonal and reproductive dysfunction, bowel and bladder functional changes, etc.

The most compelling data regarding the risks of developing a radiation-induced cancer (also known as a “secondary malignancy”) with PBT versus X-ray comes from a historical review of actual patients treated with these two modalities at Harvard. The study authors (Chung et al., International Journal of Radiation Oncology Biology Physics, 2008) reported that there was a 50% lower risk of developing a secondary malignancy among patients treated with PBT versus X-rays.

What tumors and disease sites are currently being treated with PBT?

• Brain, base of skull and spinal cord (arteriovenous malformations, brain metastases, brain tumors, meningiomas, pituitary adenomas, trigeminal neuralgia, vestibular/acoustic schwannomas/neuromas, chordomas, chondrosarcomas, etc.)
• Esophageal cancers
• Eye (uveal melanomas, pediatric orbital and ocular cancers)
• Head and neck cancers
• Liver cancers
• Lung cancers
• Lymphoma
• Pediatric cancers
• Prostate cancer
• Sarcomas

Is PBT more effective than x-ray based radiation therapy?

This remains an area of controversy, as there have been no randomized trials conducted, to date, comparing PBT to x-ray based EBRT. The data clearly indicates that when comparing individual radiation therapy treatment plans for both technologies, PBT wins in most cases. In other words, significantly higher doses can often be delivered to the tumor (using PBT) while still not exceeding the tolerance of the non-target tissues. Nevertheless, as with all new technologies, randomized trials need to be done to prove the technology is in fact an improvement over existing (less expensive) technology. As the cost for PBT becomes more affordable and the treatment facilities are scaled down in their size, there is little doubt that PBT will displace X-rays as the new mainstream technology.

What type of radiation would you rather receive…pictures speak a thousand words (examples):

In summary, the majority of PBT plans demonstrate substantially less non-target tissue radiation dose than can be achieved with X-rays.

The colorized pictures demonstrate the distribution of radiation dose. High-doses are ‘red’ and low-doses are ‘green’ or ‘blue’ (click on the images to enlarge).

Medulloblastoma (Left: X-ray, Right: PBT)

The target area is the posterior fossa (the back of the brain). The excess radiation outside of the posterior fossa is much more extensive with X-ray versus PBT treatment, thereby increasing risks and complications.

Medulloblastoma (Top: X-ray, Bottom: PBT)

Orbital Tumor (Left: X-ray, Right: PBT)

Brain Tumor (Left upper and lower: PBT, Right upper and lower: X-ray)

Spinal Tumor (Left: PBT, Right: X-ray)

Prostate Cancer (Left: PBT, Right: X-ray)

(The dose/volume graph, below, demonstrates the dose to the rectum with prostate radiation; the ‘red’ color illustrates the excess radiation dose deposited in the rectal wall with X-rays versus PBT); University of Florida data: PBT vs. X-ray: (35% less dose to the bladder, 59% less dose to the rectum)

Esophageal Cancer (Left: PBT, Right: X-ray)

Lung Cancer (Left: X-rays, Right: PBT)

Is PBT covered by insurance?

Proton therapy is typically covered by Medicare. Most other insurers will cover proton radiation therapy on a case-by-case basis.

What is the bottom-line with PBT?

Ask your radiation oncology team if proton beam therapy is a reasonable option for you.  There are many conditions for which PBT is currently being used, but may not offer a significant advantage over other technologies that your team is recommending (i.e. brachytherapy, intensity modulated radiation therapy, electron beam therapy, etc.) Based on the details of your cancer and condition, your radiation oncology team will help direct your treatment to the appropriate technology. There are many variables that are weighed in this decision: cancer type, location of the cancer, cancer stage, patient’s overall performance status, published literature suggesting advantages with one technology vs. another, clinical trial eligibility, accessibility of technologies in the community, etc.

Unfortunately, access to proton treatment centers is limited for many patients.  It is therefore quite common for patients to seek out or be referred to proton treatment centers across the country.  The majority of proton treatment facilities have staff that can assist you with coordinating travel arrangements and housing for your appointments and treatments. Financial counselors are typically available to help you better understand the insurance and payment details of this treatment.  This is expensive treatment (i.e. 30-500% more costly than the most advanced x-ray treatment), but the costs will drop over the next few years due to: reductions in construction and machine costs, exciting research demonstrating the efficacy and safety of shorter treatment courses (i.e. 5-day prostate and lung cancer treatment regimens versus 7-9 week conventional regimens, etc.) and decreased insurance reimbursement rates.

It is incumbent on proton therapy researchers and clinicians to demonstrate the superiority of PBT over existing, less costly technologies. Efficacy data will need to prove that PBT is either more effective (i.e. better tumor control), reduces toxicity (complications and side effects) and/or improves patient-reported quality of life.  I am a strong believer that high-quality studies will eventually support these findings for many cancers.

Do I believe that PBT is the best radiation treatment technology for all cancers?  No. Having been fortunate enough to train at Harvard, where we had access to PBT and many other technologies, I know the advantages (there are many) and present-day limitations for this incredible modality.  There will always be a role for the less fancy (and less costly) radiation therapy options (i.e. brachytherapy, x-ray and electron-based radiation therapy, etc.), as these alternatives are readily accessible to most patients and they are supported by a long track record of efficacy and safety.

Useful Links:

• The National Association For Proton Therapy (http://www.proton-therapy.org)
• Wikipedia (http://www.en.wikipedia.org/wiki/proton_therapy)
• Proton Bob (http://www.protonbob.com)
• IBA Proton Therapy (http://www.iba-protontherapy.com)
• ProCure (http://www.procure.com)
• Proton Therapy Cooperative Group (http://ptcog.web.psi.ch)

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Hormones are proteins that have very important stimulatory effects on tissues, organs and glands within the body. In normal physiologic states, the production and release of the endogenous (made by the body) hormones is tightly controlled. However, when the normal hormonal physiology is disturbed these hormone levels may become too high or too low, potentially leading to a variety of deficiency or excess hormone states and conditions (i.e. hypogonadism, hypo/hyperthyroidism, adrenal insufficiency, menopause, diabetes, etc.) Hormones produced by the following tissues (i.e. thyroid, pituitary gland, adrenal glands, pancreas, ovaries, testes, etc.) control all of our most important bodily functions: digestion and metabolism, reproduction, tissue growth and repair, immune system, etc.

In the vast majority of cases, these hormonal states of excess or deficiency are only diagnosed when an individual begins to manifest symptoms. The most common deficiency state is menopause, and can be associated with such troublesome symptoms (i.e. hot flashes, mood disturbances, fatigue, low-libido, vaginal dryness, etc.) that many women seek relief with supplemental estrogen. As an oncologist, one concern regarding supplemental estrogen is that it can increase the risk of breast cancer development and possibly progression (particularly in women with estrogen receptor positive “sensitive” tumors).

Low-testosterone (hypogonadism) is one of the least diagnosed and undertreated deficiency syndromes. Read my blog post to learn more about “Low T”.

Health care practitioners should only prescribe supplemental hormones to patients after a thorough discussion of the potential risks and benefits. It is alarming that some patients are being told that there are no risks with the use of the highly-marketed and hyped hormone supplementation therapy called, “bioidentical hormone therapy” (BHT). The likes of famous personalities (i.e. Oprah Winfrey, Suzanne Somers, etc.) have even touted the benefits of BHT in the treatment of menopausal symptoms. Additionally, practitioners of “anti-aging” medicine promote the use of numerous “bioidentical” hormones to help slow the effects of aging (i.e. prevent bone loss, increased muscle mass, improve libido, reduce fatigue, etc.).

What is “bioidentical hormone therapy” (BHT)?

There are multiple names for this therapy: “bioidentical hormone therapy,” “bioidentical hormone replacement therapy,” and “natural hormone therapy.” Essentially, BHT is a process for assessing an individual’s hormone levels (via blood or salivary testing) and replacing any deficiencies with synthetic hormones. Practitioners who practice BHT frequently prescribe multiple hormones at a time to their patients using pharmacy-compounded products.

What conditions are commonly treated with BHT?

The most common is menopause and the associated symptoms (It is estimated that more than one-million women in the U.S. are taking BHT for menopausal symptoms). BHT is widely promoted as an “anti-aging” therapy. (We have all seen the advertisements of the 70 year old physician who has the muscular, tanned body of a 30 year old after starting on an “anti-aging” program…think hormonal supplementation.)

Low-testosterone (hypogonadism) is one of the least diagnosed and undertreated deficiency syndromes. Read my blog post to learn more about “Low T”.

What are the most common hormones that are prescribed and how are they administered?

The most common BHT drugs include: estriol, estrone, estradiol, progesterone, testosterone, dehydroepiandrosterone (DHEA) and growth hormone.

They can be administered by injection, orally, transdermally, or with intra-vaginal preparations.

How are levels of hormones assessed and followed?

BHT practitioners rely on blood and saliva tests (i.e. estrone, E2, E3, progesterone, pregnenolone, DHEA, testosterone, and cortisol) to help determine which hormones are “low” and therefore require supplementation. These tests are repeated to assess for response to supplementation.

It is quite appealing for patients to be offered an customized hormonal therapy prescription. However, each person is unique and has varying proportions of different endogenous hormones. What is normal for one person may not be normal for others. Blood levels of a hormone may not reflect the clinically relevant, cellular effects of steroid hormones. Thus, similar blood levels in 2 different patients may result in different biological effects.  Salivary hormone assays are popular because of the ease of collection. Under ideal circumstances, salivary levels should reflect serum levels. However, salivary concentration can fluctuate greatly based on several factors: the salivary flow rate, toothbrushing, eating, time of day, etc.  Additionally, there are no well-defined and standardized goal ranges for “normal” hormone levels. Based on the limitations inherent in blood and salivary testing, the current standard of care is to individualize hormone therapy based on symptom relief and side-effect profile, not laboratory results.

Is BHT a more “natural” alternative to conventional (non-bioidentical) hormone replacement therapy?

The term “natural” can be applied to all products where the principal ingredient originates from an animal, plant, or mineral source. Both bioidentical and non-bioidentical hormones can be produced from the same “natural” sources (Fact: Soybeans and yams are used in the development of both bioidentical and non-bioidentical hormones). The use of the term “natural” is a marketing gimmick that is misleading. “Natural” does not mean safe.

FDA-approved hormone replacement therapies can be very costly, whereas compounding pharmacies typically sell BHT compounds for a lot less money. This cost-advantage enables many more people to take advantage of hormonal replacement.  

Is BHT effective and safe?

To date, the data supporting both the safety and efficacy of BHT is inconclusive.  Bioidentical hormones are expected to carry the same risks and benefits as their non-bioidentical counterparts, but there have been no studies that directly compare bioidentical hormones with their non-bioidentical counterparts. Based on high-quality trials that have studied hormone replacement therapy use over many years, we know the risks and benefits of conventional (non-bioidentical) hormone replacement therapy.  The American Cancer Society, The Endocrine Society and others have stated that these risks are expected to be the same for patients treated with BHT.

• Estrogen risks: The large Women’s Health Initiative (WHI) study randomized 16,608 postmenopausal women to combined hormones versus placebo and discovered that women given the conjugated equine estrogens plus medroxyprogesterone acetate (Prempro) had an increased risk of breast cancer, coronary heart disease, stroke, and venous thromboembolism.
• DHEA and testosterone supplementation are commonly prescribed by BHT practitioners to treat and prevent numerous conditions (i.e. mood disturbances, sexual dysfunction, enhance well-being, cognition and memory, loss of bone density, fatigue, decreased muscle strength, etc.) Low-testosterone (hypogonadism) is one of the least diagnosed and undertreated deficiency syndromes. Read my blog post to learn more about “Low T”.
• Adrenal hormone replacement: “Adrenal fatigue” is a diagnosis commonly treated by BHT practitioners. It is claimed to be responsible for a variety of symptoms (i.e. nonspecific body aches, fatigue, nervousness, sleep disturbances and digestive problems), and is treated with adrenal supplements. BHT practitioners believe that the adrenal glands burn out from chronic stress. “Adrenal fatigue” is not an accepted medical diagnosis. Unlike in patients with “adrenal insufficiency” (a well-recognized condition that can be diagnosed by blood and urine tests), assays for adrenal function and stimulation tests are often normal in patients who have been diagnosed with “adrenal fatigue” by BHT practitioners.  Patients with “adrenal fatigue” are typically prescribed dried extracts of raw animal glandular and nonglandular tissues or glucocorticoid (steroids) medications. These compounds may contain infectious material, such as prions, which can cause mad cow disease. If they contain glucocorticoids, they can suppress the body’s hypothalamic-pituitary axis, ultimately leading to adrenal insufficiency.
• BHT product quality: The pharmacy custom-compounded hormones (typically used in BHT) are not regulated by the FDA, so there is no guarantee of purity, potency, efficacy or safety, and they may contain unknown contaminants.

Unfortunately, many practitioners continue to market BHT as if the science is supportive of both efficacy and safety.

Concerned that patients are being deceived into believing that these therapies are natural, safe and effective, numerous medical organizations have released statements warning patients of the potential risks (some of which are life-threatening) associated with BHT. As of 2011, the following organizations have released such statements: The International Menopause Society, American Congress of Obstetricians and Gynecologists, Society of Obstetricians and Gynaecologists of Canada, The Endocrine Society, the North American Menopause Society (NAMS), United States Food and Drug Administration, American Association of Clinical Endocrinologists, American Medical Association, American Cancer Society and the Mayo Clinic.

In conclusion:

I support the use of BHT as long as my patients are well-informed:

• To date, there are no robust, quality and long-term data supporting the safety and efficacy of these therapies.
• Comparative studies between BHT and conventional HT replacement have not been conducted.
• Conventional hormone replacement therapy is prescribed not solely on laboratory assessed hormone levels, but instead based primarily on the individuals’ symptoms and only after thoroughly reviewing the potential risks and benefits with the patient. BHT is prescribed based on results of hormone levels from assays (saliva and blood), levels that may not make any sense clinically or physiologically.
• BHT is not any more “natural” or safe than non-bioidentical hormone therapy. BHT may increase the risk of developing certain cancers and cancer progression. Cancer can increase the risk of blood clots in some patients. BHT may further increase the risk of risk of cardiovascular conditions (i.e. stroke, blood clots, etc.).
• Low-testosterone (hypogonadism) is one of the least diagnosed and undertreated deficiency syndromes. Read my blog post to learn more about “Low T”.

I highly recommend that patients discuss their use or interest in BHT with their cancer care team to make sure they have been carefully counseled on the potential risks.

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When smoking herbal/botanical compounds (think: cigarettes, cigars, pipes, etc.), an individual inhales a long list of toxins and carcinogens that are produced during combustion. Filters and water pipes (i.e. bongs, hookahs, etc.) remove only a fraction of these dangerous molecules.

Along comes the vaporizer:

The vaporizer is a safer inhalational option. The two main components of any vaporizer are: 1) a heating element (with or without a temperature control feature), 2) a chamber to hold the botanical compound.

Instead of burning (combustion), vaporizers gently cook the plant material in the enclosed chamber. Depending on the vaporizer, it typically takes between 5-60 seconds of heating before vapor is produced. Each botanical agent has a defined temperature range at which the desired bioactive molecules are released from the raw plant as a gas vapor (see the temperature ranges below).

Since vapor is produced at lower temperatures than it takes to burn the plant material, essentially none of the toxic chemicals are produced.  Overall, vaporizing is a safer inhalational option than smoking, and without having to inhale the noxious chemicals in smoke there is minimal throat irritation or burning.

Controlling potency and concentration:

These can be controlled by the amount of vapor inhaled and by the temperature selected on the vaporizer. Lower temperatures produce less vapor (and a lower concentration of active compounds) than the higher temperatures. As the temperature is increased, more aromas and flavors are released.  If you set the vaporizer’s temperature too high, the vapor will become yellow-grey in color. This is an indication that you have reached combustion temperatures and smoke is starting to form. Adjust the vaporizer to a lower temperature setting to eliminate combustion and smoke.

If you are already smoking or considering using medicinal botanicals (i.e. marijuana, tobacco, peppermint, sage, etc.), consider purchasing a vaporizer with an adjustable temperature control. This will enable you to use various plant medicinals and achieve the best results.

(**although not the subject of this blog entry, if you are using smoked tobacco products and want to reduce your risk of developing cancer and lung disease…consider using an electronic cigarette instead. These are mini-vaporizers that look like cigarettes and they deliver nicotine vapor without the toxic chemicals produced during the combustion of tobacco. Nicotine is a very addictive chemical, so don’t start using electronic cigarettes if you are not already smoking.**)

What can you vaporize and where can you purchase one?:

Vaporizers commonly use dried (easier to vaporize) or fresh plant material, although some vaporizers can also use liquid extractions of plant materials.

You can purchase a vaporizer easily through internet stores, and the prices range from under $100 to over $1000 depending on the model. There are many manufacturers to chose from, and new/fancier models and features are constantly becoming available.

As with any botanical medicinal, there are a variety of important factors to pay close attention to before using them:

• Botanicals are medicine. They are comprised of numerous molecules that have bioactive effects. (see references at the bottom of this blog entry)
• Always discuss your use of these substances with your medical team. As with any medication, their use can lead to serious side effects and potentially dangerous drug-botanical interactions.
• Only obtain plant products from reputable manufacturers/suppliers. Adulteration of plant compounds with other (often unspecified) ingredients is not uncommon. Additionally, batch-to-batch variability in product quality and potency is a concern when using botanicals from less reputable suppliers.

Here is an abbreviated list of some of the more commonly vaporized medicinal botanicals:

*these botanicals have been used for thousands of years in the treatment of these conditions (This is NOT an endorsement of these botanical compounds and indications. This is only for informational purposes.)*

• Camomille: relaxes emotions and muscles, relieves pain, stiff joints, headaches, sore muscles, menstrual and digestive system cramping
• Damiana: stress reduction
• Eucalyptus: relieving sinus and lung congestion, cough and asthma
• Green Tea: pain reliever, aids in digestion (pain, gas, bloating, nausea)
• Lavender: relieves muscle pain, migraines and other headaches, indigestion, reducing stress
• Lemon Balm: helps with insomnia, reducing stress, relieve spasms, cramps and reduce pain
• Marijuana: relieves pain, nausea, improves appetite, aids in relaxation and insomnia
• Passion Flower: sedative, insomnia
• Peppermint: aids in digestion (pain, gas, bloating, nausea), pain reliever (especially headaches)
• Raspberry Leaf: relieves nausea and upset stomach
• Sage: reduces sweating, aids in digestion
• Spearmint: aids in digestion, relaxation, respiratory problems (bronchitis, asthma, sinusitis)
• Thyme: relieves muscle spasms, expectorant

Listen to Dr. Donald Abrams (University of California San Francisco/Osher Institute and San Francisco General Hospital, Medical Oncologist and Integrative Oncologist) talk about the research his group conducted which found that vaporization is a safer and more enjoyable delivery method for inhaling botanical medicinals than smoking without reducing the efficacy of the active ingredients.

Vaporization Temperatures:

Low temperature: up to 150°C (302°F)

Medium temperature: up to 175°C (347°F)

High temperature: up to 200°C (392°F)

Two of my favorite resources on plants as medicines are:

• The Medicine Hunter.com
• The Rosenthal Center for Complementary and Alternative Medicine (Columbia University)

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• immune stimulating/enhancing effects
  • stimulation of cytotoxic T cells and enhanced natural killer (NK) cell activity
• anti-viral effects (active against: herpes, human papilloma virus, Epstein Barr virus)
• anti-bacterial effects
• anti-cancer effects (i.e. pro-apoptosis, anti-angiogenic, inhibition of tumor cell migration and invasion, etc.)
  • The extract “PSK” (see below) has shown to have anti-cancer (improving progression free survival and/or overall survival) as an adjuvant therapy in a variety of cancer types: gastric, esophageal, colorectal, breast and lung cancers.

One of the fungi that seems to be most consistently associated with these beneficial effects is, Coriolus versicolor (also known as: Trametes versicolor, Polyporus versicolor, Polystictus versicolor, Turkey Tail, Yun Zhi, Kawaratake). Extensive research has identified 2 polysaccharide-protein (proteoglycan) components of Coriolus versicolor (CV) that are responsible for most of these effects:

• Polysaccharide Kurcha or Polysaccharide-K (PSK or Krestin)
• Polysaccharide-protein complex (PSPC or PSP).

PSK and PSP are widely used in China and Japan to improve the outcomes of patients with cancers of the gastrointestinal system, breast cancers and lung cancers. Frequently these extracts are combined with conventional therapies (i.e. chemotherapy, radiation therapy). Complications and side-effects attributable to PSK, PSP or whole mushroom supplements are rarely reported.

Processing the mushrooms through hot water or alcohol extraction enables manufacturers to obtain concentrations of the bioactive components at levels significantly higher than can be consumed from the whole mushroom. For thousands of years, traditional Chinese medicine practitioners have similarly employed the use of hot water preparations (called “decoctions”) to dissolve and extract the medicinally active compounds from various botanicals, including mushrooms.

Although most of the scientific studies have been conducted using single agent hot water extracts (i.e. PSK and PSP), I typically recommend taking a supplement that contains a variety of different mushroom extracts. Combining multiple extracts together may have a synergistic advantage (over a single extract). Many supplement manufacturers offer combination mushroom supplements that include a variety of fungi that have been reported to have beneficial health effects. Only select supplements from manufacturers who practice the highest quality control (i.e., BirkMeds, Fungi Perfecti, etc.)

**Always discuss the use of any supplements with your cancer care team before starting them**

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The first study examined the use of a fish oil supplement (2.5 grams of EPA + DHA/day) in patients undergoing first-line chemotherapy for non-small cell lung cancer. The control group of patients only received chemotherapy. The authors found at one year:

• A significant improvement in the response rate to the chemotherapy in those patients that received the fish oil supplement versus the chemotherapy-only group (60.0% vs 25.8%, P = .008).
• Although not statistically significant, the  one-year survival was higher in the fish oil group versus the control group (60.0% vs 38.7%; P = .15). (**Clearly this finding needs to be further assessed in larger, more robust trials to confirm this promising result**)

The second study examined the potential of a fish oil supplement (2.2 grams of EPA/day) to help maintain weight in patients undergoing chemotherapy for non-small cell lung cancer. The control group of patients again only received chemotherapy (no fish oil supplements). The authors reported:

• Patients in the control group (no fish oil supplements) lost an average of 2.3 ± 0.9 kg.
• Patients receiving the fish oil supplement maintained their weight (0.5 ± 1.0 kg) (P = .05)
• 69% of patients in the fish oil group gained or maintained muscle mass (only 29% of patients in the control group maintained muscle mass, and overall the SOC group lost 1 kg of muscle.)
• There was no difference in total adipose tissue was observed between the 2 groups

Calendula officinalis

Radiation therapy commonly causes an inflammatory skin reaction in the radiated tissues called, radiation dermatitis. This is characterized by skin redness, irritation or pain, swelling, and peeling or blistering.

As a radiation oncologist, I frequently counsel my patients on skin care during treatment and one of my favorite recommendations is to use Calendula cream (or cream or oil formulations that include Calendula) throughout the course of therapy. I recommend applying the cream to the irradiated skin 2-3 times each day (please discuss this with your own radiation oncology team to get their approval).

A large study was published, in 2004, in the Journal of Clinical Oncology, that demonstrated a very significant reduction in the risk of developing the radiation dermatitis (35% reduced risk) while using Calendula cream versus Trolamine (a skin cream that was widely used for the treatment of radiation dermatitis). Furthermore, the use of Calendula reduced pain levels by 27% over Trolamine.

You can purchase Calendula creams at many health food chains (i.e. Whole Foods Market) and supplement stores. Select formulations with no added perfumes or oddly sounding artificial chemicals.

My favorite recommendations are:

• Miaderm (Aiden Industries)
• Calendula Body Oil (bodyceuticals)
• Organic Calendula Salve – for body & face (bodyceuticals)

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Having used this treatment for many of my patients (men and women) with hormone therapy-induced hot flashes, I am not surprised at the published results.

The patients included a small cohort of men with prostate cancer who were being treated with androgen deprivation therapy (ADT). The investigators used a simple protocol of electroacupuncture (sorry for the acupuncture lingo to follow: 10 bilateral points at GB34, SP6, KI3, ST36, BL15, BL23, Taiyang, HT7, PC6, LI11; De Qi was elicited at all points and 2Hz was applied at SP6, ST36, BL15, BL23). The treatments each lasted 30 minutes and were done twice a week for 4 weeks.

Patients were given a hot flash score (HFS) questionnaire to complete for the entire length of the study. The HFS is a product of the hot flash frequency and severity (1=mild, 2=moderate, 3=severe). The HFS is an accepted assessment used in many other studies.

The results were fantastic:

• Mean improvement in HFS at 2-weeks=68% and at 6-weeks=89%.
• Amazingly, 8-months after the completion of the acupuncture treatment, the patients still recorded a mean improvement of 80% from their pre-acupuncture baseline!!
• There were no side effects from this treatment.

If you are living with hot flashes from ADT, give acupuncture a try.

Learn more about complementary therapies in cancer care here.

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Read the study here

The probiotic regimen: 2 × 109 units of a lactobacillus acidophilus plus bifidobacterium bifidum (equivalent to 2 capsules) two times a day before meals (morning and evening), beginning 7 days before starting radiotherapy and continuing everyday during radiotherapy.

*This was a relatively small randomized controlled trial (RCT), so the results can not be generalized. Although this study is compelling, the results should be confirmed by more robust studies with greater numbers of patients.*

What are probiotics?

Probiotics are live microorganisms (in most cases, bacteria) that are similar to beneficial microorganisms found in the human gut (such as the two employed in the above study). They are also called “friendly bacteria” or “good bacteria.” Data suggest that there may be enhanced synergistic effects when multiple probiotics are combined.

How might probiotics work in reducing radiation-induced diarrhea?

Radiation therapy (and chemotherapy) can cause a temporary inflammatory response within the affected bowel. If the degree of inflammation is significant, it can lead to reduced absorption of nutrients and water and impair the growth of normal ‘healthy’ intestinal bacteria that colonize the bowel (aiding in digestion, regulating bowel elimination, and possibly enhancing immune function) Reduction in the amount of normal bowel bacteria can lead to an opportunistic increase in growth of competing ‘unhealthy’ microorganisms, leading to further impaired digestion. The science on the physiology, mechanisms of action and efficacy of probiotics remains an area of controversy.

Safety concerns:

As probiotics are “live” microorganisms, use of these supplements should be first discussed with your physicians if you are immunocompromised. There have been rare reports of bacterial infections in the blood (septicemia) of individuals who used probiotics. Probiotics are not regulated by the Food and Drug Administration as they are considered food or supplements. Product quality, consistency and composition are not all the same among the different brands and batches. It is important to only purchase supplements from the most reputable manufacturers.

Learn more about probiotics on the National Center for Complementary and Alternative Medicine (NCCAM) website

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Based on a recently reported study of over 30,000 men with prostate cancer, radiographic staging studies are being inappropriately used in 36% of men with low-risk disease and 49% of the time in those with intermediate-risk disease.

These findings raise obvious potential health concerns for many patients (i.e. exposure to ionizing radiation from CT scans and bone scans increases one’s risk of developing cancer), and should be recognized as an unnecessary (and significant) expense to our patients and the already overburdened healthcare system. “This is a perfect example of how we are wasting money on inappropriate tests and the denying other people of appropriate care.” (Dr.Mack Roach, University of California, San Franscisco, Professor and Chair of Radiation Oncology and Professor of Urology)

Widely accepted oncology guidelines (i.e. National Comprehensive Cancer Network) only recommends radiographic staging on all patients with high-risk cancers (i.e. Gleason scores 8-10, clinical T3-T4 tumors, PSA >20 ng/ml), as these individuals have a significantly greater risk of extraprostatic cancer at presentation. Radiographic staging is employed in these patients to help direct therapeutic management decisions. One of the most concerning findings of this study was that 39% of men with high-risk prostate cancer did not receive any radiographic staging.

To learn more about pretreatment radiographic staging studies in prostate cancer, the American College of Radiology has established appropriateness guidelines that are based on a variety of diagnostic variables (i.e. Gleason score, PSA, clinical stage, number of positive biopsies).

I often provide my patients with references from the National Comprehensive Cancer Network (NCCN). The advisors for the NCCN comprise experts from numerous academic institutions. These experts typically update their guidelines at least once a year. I find their prostate cancer patient guide to be very user-friendly. It includes information on diagnostic tests, risk categories, management options and side effects. The flowcharts (pages 44-52) are great visual aids for better understanding staging, treatment and follow-up recommendations.

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Read the presentation here:

Dr. Mark Moyad (University of Michigan, Professor of Preventive and Alternative Medicine) is a great educator on this topic. He often states that if you want to get the biggest bang for your buck, reduce your risk of dying from cardiovascular disease (the #1 most common cause of death in men and women.) By eating a “heart healthy” diet and exercising (30 minutes a day, at least 5 days each week), you are significantly decreasing your risk of dying from cardiovascular disease…and from developing numerous cancers.

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As defined by the U.S. National Cancer Institute: “The terms spirituality and religion are often used in place of each other, but for many people they have different meanings. Religion may be defined as a specific set of beliefs and practices, usually within an organized group. Spirituality may be defined as an individual’s sense of peace, purpose, and connection to others, and beliefs about the meaning of life.“

Asking patients about their religious or spiritual coping often opens the door to further discussion about this topic, and is typically perceived as a validation of the importance of this experience. Studies report that inquiring about spirituality and religion in this context is well-received and rarely considered intrusive or distressing to patients. Increasingly, medical schools are incorporating interviewing skills into the curriculum that address spiritual well-being.

There are numerous semi-structured interviewing tools that are available to healthcare providers that help them explore a patients’ religious beliefs and spiritual experiences or issues and identify possible areas of concern. Additional resources can then be offered to their patients such as a referral to a chaplain or support group.

Read more about Religion and Spirituality in cancer care.

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To help these patients and their loved ones better cope with the serious challenges of being a parent with cancer, I started looking for resources. One of the best I could find was the excellent series of guides from the American Cancer Society. If you know anyone who might find these helpful, please pass this information along:

• DEALING WITH DIAGNOSIS (Families with young children or teens may be concerned about how children will react to a diagnosis of cancer in a family member. Here we discuss how to help children understand and deal with a parent or close family member’s cancer diagnosis.)
• DEALING WITH TREATMENT (Explaining cancer treatment to children can be a tough job, especially when you are already trying to deal with your own feelings and emotions. What you tell your children depends on many things, like their ages, personalities, and what you know about the treatment.)
• DEALING WITH RECURRENCE OR PROGRESSIVE ILLNESS (For a person with cancer, one of the hardest things to go through is when the cancer keeps growing during treatment or comes back after treatment. It is hard for their loved ones, too, including children and teens. Here we will try to help you understand what your children might be thinking and feeling, and share some ideas on how you may be able to help them through this time.)
• UNDERSTANDING PSYCHOSOCIAL SUPPORT SERVICES (Cancer can affect the entire family — both adults and children — in many ways. Psychosocial support includes mental health counseling, education, group support, and many other such services. These services are usually provided by different types of mental health professionals. Here you can learn more about the psychosocial support services that may be available to you and your family.)
• DEALING WITH A PARENT’S TERMINAL ILLNESS (All parents want to protect their children from the pain that life can bring. As hard as it might be to think about what children need during a terminal illness, we hope your burden will be eased in some way by taking steps to help them prepare and cope.)
• WHEN A CHILD HAS LOST A PARENT (Children of all ages go through grief, sadness, and despair after the loss of a parent to cancer, even though the process might look different from that in adults. This short guide is offered to help you get started looking into deeper and ongoing resources to help a child who has lost a parent.)

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The latest USDA dietary recommendations incorporates most of the same recommendations that are touted under different names:

• “Heart healthy diet”
• “Anti-cancer diet”
• “Anti-aging diet”
• “Anti-Alzheimer’s disease diet”
• “Anti-inflammatory diet”
• “Anti-diabetes diet”
• “Mediterranean diet”
• “Japanese diet”
• …and the list goes on…

In summary, these are the recommendations:

• Consume less total fat (especially saturated fat)
• Maintain a healthy caloric balance (through a combined approach of calorie intake and physical activity)
• Increase your intake of fruits and vegetables, beans and grains
• Decrease your intake of processed foods, simple carbohydrates (i.e. refined sugars, flours and grains), and artificial chemicals (i.e. coloring and preservatives)
• Limit your consumption of high-glycemic index foods, while preferentially consuming low-glycemic index foods
• Limit your intake of protein from foods higher in saturated fats (i.e. dairy and red meat), in favor of plant and fish based proteins
• Although not a dietary recommendation, most studies demonstrate that 150 minutes of physical activity each week is associated with improved health outcomes (The U.S. Department of Health & Human Services has a great guide I highly recommend: “2008 Physical Activity Guidelines for Americans“)

There really isn’t anything new and exciting here. This is simply a restating of many of the recommendations that we have all intuitively known…but many of us have found hard to commit to and follow.

By following these recommendations, you will significantly decrease your risk (estimated: by 20-50%) of dying from the most common causes of death in men and women: cardiovascular disease, cancer, Alzheimer’s disease, and diabetes.

Imagine if you could take a magic pill that would consistently and safely deliver similar results…my guess is that this pill would quickly become the most lucrative drug ever developed and the research team would be nominated for a Nobel Prize in Medicine.

Visit the IntegrativeOncology-Essentials.com to learn more about how diet and physical activity may contribute to cancer development, recurrence and progression.

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I developed the IOE WEBSITE, BLOG and the Integrative Oncology Essentials: A Patients’ Guide To Cancer Care And Prevention as a means of sharing up to date “Integrative Oncology” news, information and resources with my patients.  I hope that this content is helpful to anyone living with or beyond a diagnosis of cancer.”

Download the new 2011 guide here.

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This study, albeit a mouse experiment, is still very intriguing and is consistent with findings from other groups (suggesting that diets higher in saturated fats lead to increased risk of cancer development, progression and recurrence.)

The importance of consuming a diet low in saturated fats (i.e. meat, dairy) is one of the main topics of discussion during an integrative oncology consultation.

I cover this subject in detail on the IntegrativeOncology-Essentials website- click here to learn more.

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Although the authors stated that these results were limited to those who performed ”vigorous” physical activity for at least 3-hours each week, participating in less vigorous exercise (i.e. walking, jogging, biking, gardening) for even 15-minutes each day was also protective against the risk of dying of any cause.

Similar findings were recently reported (in Cancer Epidemiology, Biomarkers & Prevention, in December 2010) for colorectal cancer. Investigators found that among individuals who conducted regular physical activity (for 10-years or more) there was a significantly lower risk of developing colorectal cancer, and that regular exercise (for 15-years or more) was associated with a 50% reduction in the risk of dying from colorectal cancer.

One of the main topics of discussion during an integrative oncology consultation is on the importance of physical activity and exercise. I have included a great deal of information on this important topic on my website. Click here.

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HNPCC/Lynch syndrome is reported to be present in up to 4% of all individuals diagnosed with colorectal cancer and in up to 5% of all women who have been diagnosed with endometrial (uterine) cancer.

Carriers of the HNPCC/Lynch Syndrome gene mutation have an increased risk of developing:

• Colorectal cancer (lifetime risk: 35-82%)
• Endometrial/uterine cancer (lifetime risk: 34-71%)
• Stomach cancer (lifetime risk: up to 13%)
• Ovarian cancer (lifetime risk: up to 12%)
• Second colorectal cancer (within 10 years: 30%; within 15 years: 50%)
• Kidney/urinary tract cancer
• Brain cancer
• Biliary tract cancer
• Pancreatic cancer
• Small bowel cancer

The following risk factors place you at a higher risk of having HNPCC/Lynch Syndrome:

• A personal diagnosis of colorectal cancer before the age of 50
• A personal diagnosis of endometrial/uterine cancer before the age of 50
• Two or more Lynch Syndrome-related cancers (see the list above) diagnosed in you or a family member
• Two or more members of your family have been diagnosed with a Lynch Syndrome-related cancer (see list above)
• A family member with a known Lynch Syndrome mutation

How is HNPCC/Lynch Syndrome diagnosed? A very simple collection of cells from the inside of your mouth is all it takes. These cells are either obtained by a swab or by a mouthwash rinse that you swish and spit into a container. This container is then sent off to the lab for analysis.

If you carry this gene mutation, there is up to a 50% chance that one of your parents, your children, and/or a brother or sister will also have this mutation…so it is important to discuss genetic testing with them.

How is HNPCC/Lynch Syndrome managed? Most genetic counselors will recommend early cancer surveillance:

• Colorectal cancer: colonoscopies; every 1-2 years (starting between 20-25 years old, or 5-10 years earlier than the youngest colorectal cancer in the family, or at 40 years old; whichever comes first)
• Endometrial and Ovarian cancer: gynecologic exam, transvaginal ultrasound, endometrial tissue sampling, CA-125 blood test; every 1-2 years(starting at 25-35 years old)
• Screening for other Lynch Syndrome-related cancers (see list above) may be considered based on the presence of those cancers in a family member
• Surgical management:
  • Removal of the colon (“colectomy”) is performed in those who develop colon cancer.
  • Prophylactic colectomy can be performed for those who do not wish or are unable to undergo screening colonoscopies
  • Prophylactic removal of the uterus and/or ovaries (“hysterectomy” and “oophorectomy”) will reduce the risk of developing endometrial and ovarian cancers, and may be considered for those who no longer wish to or able to bear children

What is this test going to cost me?

• The majority of patients who are at increased risk of having a HNPCC/Lynch Syndrome mutation are covered for testing and paying a copay of less than 10%. Most patients have no out-of-pocket costs for this test.

If you test positive for a HNPCC/Lynch Syndrome mutation can any health care insurance company determine your eligibility or charge you higher rates?

• No. The federal law “HIPAA” prohibits insurance companies from using the results of genetic testing in determining your eligibility for coverage and they can not charge you a higher rate.

**If after reading this post and you feel you may be a candidate for HNPCC/Lynch Syndrome genetic testing or you would simply like to learn more about it, please discuss this with your cancer care team.**

Unfortunately, only 2% of individuals who have HNPCC/Lynch Syndrome have been diagnosed!

What are the risks associated with the presence of a BRCA gene mutation?

• In women (lifetime risk):
  • up to an 87% risk of developing breast cancer
  • up to a 44% risk of developing ovarian cancer
  • up to a 64% risk of developing a second breast cancer
• In men (lifetime risk):
  • up to a 7% risk of developing breast cancer

Who is at an increased risk for having a BRCA gene mutation?

(If you answer ‘yes’ to any of these, you are likely a candidate for genetic testing.)

• A family member has a previously identified BRCA mutation
• You were diagnosed  with breast cancer (at or under the age of 45 years old)
• You were diagnosed with breast cancer (at or under the age of 50 years old) and you have one or more close blood relatives with breast cancer that was diagnosed at or under the age of 50 years old
• You have been diagnosed with two separate breast cancers (one of which was diagnosed when you were under the age of 50 years old)
• You have been diagnosed with breast cancer (at any age) and you have 2 or more close blood relatives with a breast, ovarian or fallopian tube cancer at any age
• You have been diagnosed with breast cancer (at any age) and you have a close male blood relative with breast cancer
• You have a personal history (at any age) of having both breast cancer and ovarian or fallopian tube cancer
• You are of Ashkenazi Jewish ethnicity and have been diagnosed (at any age) with a breast, ovarian or fallopian tube cancer
• You were diagnosed with an ovarian or fallopian tube cancer (at any age)

What can you do if you have a BRCA mutation in managing your risk of breast or ovarian cancer?

• Increased surveillance:
  • monthly self breast exams starting between 18-21 years old, and
  • annual or semi-annual clinical breast exams starting between 25-35 years old
  • annual or semi-annual transvaginal ultrasound and testing for CA-125 (blood test) to screen for ovarian cancer starting between 25-35 years old
• Chemoprevention (taking certain medications may decrease your risk of developing breast and ovarian cancer):
  • Drugs such as Tamoxifen may reduce the risk of breast cancer
  • Oral contraceptives may reduce the risk of ovarian cancer (by up to 60%)
• Preventive Surgery:
  • preventive mastectomy significantly reduces the risk of developing breast cancer (by greater than 90%)
  • preventive removal of the ovaries significantly reduces the risk of developing ovarian cancer (by up to 96%)

What is this test going to cost me?

• The majority of patients who are at increased risk of having a BRCA mutation are covered for testing and paying a copay of less than 10%. Most patients have no out-of-pocket costs for this test.

If you test positive for the BRCA mutation can any health care insurance company determine your eligibility or charge you higher rates?

• No. The federal law “HIPAA” prohibits insurance companies from using the results of genetic testing in determining your eligibility for coverage and they can not charge you a higher rate.

How is the test administered?

• You will be asked to swish and spit a solution of mouthwash into a container. This liquid is then sent to the lab and analyzed. (In the liquid are cells from your tongue and cheeks that are able to be tested for the BRCA mutations.)

Testing for BRCA gene mutations (if you are at an increased risk of having the BRCA mutation) before undergoing surgery for breast cancer is highly encouraged, as your surgeon and cancer care team may recommend preventative mastectomy and/or ovary removal all during the same operation. This has the advantage of sparing patients from having to undergo a second operation later. The typical turn-around time for getting the results back on the BRCA test is between 1-2 weeks, which is quick enough to not cause a significant delay in surgical treatment of the breast cancer.

As an integrative oncologist, I spend time counseling my patients on genetic testing (i.e. breast, ovarian, colorectal, melanoma, and other cancer syndromes) whenever I identify a high-risk individual.

Click here to learn more about genetic testing.

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A course of SBRT frequently involves 3-5 daily doses of external beam radiation. Each treatment session can last between 15-60 minutes, depending on the device/technology used.

SBRT is now considered the standard treatment option for patients with early stage lung cancer (stage 1, T1-2N0M0, non-small cell cancer) who are either elderly or have medical conditions (i.e. emphysema, COPD, diabetes, heart disease, etc.) that would place them at a high-risk from potential surgical complications.

Patients with early stage lung cancer who are healthy enough for surgery can select SBRT for early stage lung cancers, although to date, surgery remains the “gold standard” treatment. There are multiple clinical trials that are currently evaluating the role of SBRT in medically operable (healthy) patients with early stage lung cancers.

You can search for actively recruiting clinical trials through the U.S. National Cancer Institute website.

To find out if you are eligible for this short-course treatment, you will need to discuss this with your oncology team.

There are multiple devices/technologies that can be used to deliver stereotactic body radiation therapy (for example):

• Trilogy/iX/TrueBeam (with RapidArc)
• Novalis
• Tomotherapy
• CyberKnife
• Proton beam

All of these devices/technologies are essentially equivalent in terms of their ability to precisely and accurately deliver a high-dose to the tumor while minizing doses to the surrounding normal tissues. No clinical studies have demonstrated superiority among these machines, so don’t be swayed by the name of the machine (i.e. CyberKnife, Triology, TrueBeam, Tomotherapy, Novalis, etc.) when selecting the radiation oncology practice for your treatment. Again, they all do essentially the same thing, and no studies have demonstrated that any one of them is clinically superior.

The most important factors in selecting the right team are the reputation, training and experience of the radiation oncologists and their support staff (physicists, dosimetrists, therapists, nurses, etc.) in treating lung cancer using SBRT.

To ensure that you are receiving the highest quality of radiation oncology care, I recommend that you select a center that is accredited by either the American College of Radiology (ACR) or the the American College of Radiation Oncology (ACRO). To find a list of accredited centers in your area select the following links:

• ACR
• ACRO

Learn more about radiation therapy.

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They found the following risk reduction in cancer deaths:

• prostate cancer (10% risk reduction)
• lung cancer (30% risk reduction)
• colon, rectal, pancreatic, and stomach cancers (40% risk reduction)
• esophageal and throat cancers (60% risk reduction)

The researchers suggest that the best time to start taking a low-dose baby aspirin would be in a person’s mid-40′s, the time when the risk of most cancers begins to rise significantly.

Aspirin has many anti-cancer effects, including encouraging  precancerous/cancerous cell death (“apoptosis”) and  acting as a systemic anti-inflammatory agent.

Recent studies have also shown that aspirin may significantly reduce  the risk of developing precancerous colon polyps and prostate cancer recurrence (by up to 50%!)

If you are not currently taking aspirin but have been considering it, I recommend first discussing the potential risks and benefits with your health care team. Serious risks are uncommon but can be exacerbated (i.e. bleeding, stomach ulcers/gastritis, etc.) by co-existing medical problems as well as numerous medications.

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