CHAPTER 39
Complementary Alternative Medicine
Jessica Richards and Mark William Kissin
INTRODUCTION
Over the past 100 years, with the aid of surgery, radio therapy, hormone therapy, chemotherapy and immunotherapy, huge advances have been made in the fight against breast cancer. However, even now, not every patient is cured, and in addition some patients suffer from both the cancer itself and its treatment. Every attendant breast physician will, at some point in their career, come across a patient who has a wish to choose an alternative vision for their treatment. The correct approach, and one that satisfies ‘duty of care’, is for that physician to listen, inform, empathise and support such patients and help guide them along their chosen path. Such an approach may facilitate the combination of conventional therapy alongside the alternative measures.
The use of complementary and alternative medicine (CAM) by cancer patients is becoming more prevalent, with breast cancer patients being the most avid users. As many as 75% of breast cancer patients will be using some kind of CAM therapy. Some will seek CAM alone, with or without medical supervision, while others will want to use CAM in conjunction with biomedical treatments. Age, higher education and higher income are predictive indicators of CAM use. Information is gained via the internet, patient groups, access to online research, charities and private clinics.
Reasons for choosing CAM will include active coping behaviour, reducing side effects, increasing efficacy of biomedical treatment, enhancing quality of life and long-term survival, and fear or lack of trust in conventional medical treatments. Interestingly, few patients will disclose CAM use to their medical team but most will readily discuss their medical treatment with their CAM practitioners and with online groups. Non-disclosure of CAM can be as high as 77%. Reasons for non-disclosure to oncology teams include the team is perceived as being unable to offer any added value to what patient already knows or the information the patient already has access to, initial hospital encounter with a specialist was unnecessarily harsh, uncaring or insensitive, fear or experience of ridicule and disrespect if subject is broached in a medical consultation, and fear or experience of being refused access to hospital if patient wishes to delay conventional treatment and discuss CAM.
Non-disclosure can result in potential damaging treatment interactions and unreliable drug data. With so many breast cancer patients choosing CAM, effective collaboration between doctors and patients is more relevant than ever. The following chapter lists the most popular CAM treatments, products and practices being used by breast cancer patients.
DIET-RELATED THERAPIES
Gerson Therapy (GT)
This was developed by Dr Max Gerson (1881-1959) with the intention of stimulating the body’s own immune defences while readjusting the balance of intracellular waste products. Once both parts of this equation are rectified, Gerson argued that the diseased body will be restored to full health. Although there is no doubt that this therapy has had some notable anecdotal success, there are no scientific data to support its use. The GT regime includes five coffee enemas per day, with extra castor oil ones on alternate days. The rest of the time is spent making and drinking vegetable juices for up to 2 years to fully cleanse the body. It includes a deliberate excess of minerals, enzymes and vitamins, while avoiding the toxic pesticides and herbicides present in conventional food by using only organic versions. Milk, soya and pulses are excluded. All water used for cooking or rinsing must be distilled or produced from reverse osmosis sources, plastic containers and aluminium foil are avoided, and all juices and vegetables must be consumed within 20 minutes of preparation. This is a quite punishing protocol and requires a single minded devotion by the patient.
Probiotics
The human microbiome, the foundation of the immune system, refers to the community of bacteria that colonise our gut. Unfortunately, cancer patients may have an overgrowth of unhealthy gut flora which is worsened by the effects of chemotherapy. To counteract this process, patients can take probiotics, which are healthy bacteria which, in turn, control the over growth of rogue bacteria. Prebiotics are indigestible carbohydrates that selectively feed the probiotics. Live probiotic cultures are found in fermented dairy products such as yogurt, kefir and buttermilk. Other sources include kimchi, miso, soy and sauerkraut. Well-known prebiotics include chicory root, Jerusalem artichoke, dandelion, garlic and leek.
WHO’S WHO
• Max Gerson (1881-1959): German-born American physician
• Johanna Budwig (1908-2003): German biochemist
• William Coley (1862-1936): American orthopaedic surgeon and ‘Father of Cancer Immunotherapy’
Budwig Protocol
Developed by Dr Johanna Budwig in the 1950s, the diet consists of a mixture of flax oil (which has been shown to exert anti-cancer activities) and cottage cheese, as well as vegetables, fruits, and juices. It prohibits consumption of sugar, animal fats, shellfish, processed foods, soy and most dairy products, and encourages daily sunbathing. It is often combined with coffee enemas. Budwig believed that cancer was caused by a lack of polyunsaturated fatty acids.
Ketogenic Diet (KO)
Here, the basic principle is that cancer cells need to ferment glucose in order to survive, whereas healthy cells can switch to burning fat. Various pre-clinical studies support its use to help retard cancer growth. The diet balance is high fat (F), adequate protein + low carbohydrate (P/C), with either a 3F to 1P/C or 4F to 1P/C ratio. There is increasing evidence that high plasma glucose levels are linked to greater cancer risk and lowered survival in those already with cancer. Thus, the KD may have a preventative role as well. It must be remembered that this diet may have some serious metabolic consequences and is recommended only for short-term use.
Fasting and Intermittent Fasting
Many patients these days will utilise the benefits of fast ing even if they are not following a full ketogenic diet. Fasting and calorie restriction can slow and even stop cancer progression and tumour growth, kill cancer cells and significantly improve chemotherapy and radiotherapy effectiveness. One study of >2,400 patients with 7 years median follow-up, showed that overnight fasting
>13 hours reduced breast cancer recurrence by 36% and breast cancer death by 21%.
ANTIOXIDANTS AND OXYGEN AFFECTING THERAPIES
Medicinal Cannabis Oil
Cannabidiol (CBD) is the major non-psychoactive constituent of cannabis. Marijuana grown for recreational purposes often contains more tetrahydrocannabinol (THC) than CBD. Using selective breeding techniques, cannabis with high levels of CBD and near-zero levels of THC have been produced. CBD has a greater affinity for the CB2 receptor, interacting with the nervous system without eliciting any psychoactive effect. CBD health benefits include antioxidant, antiemetic, anticonvulsant, antitumoural, and anti-inflammatory effects. CBD has also been found to co-ordinate apoptosis and autophagy, resulting in the death of breast cancer cells without harming healthy breast cells and is thus a natural form of chemotherapy. In the UK, hemp is theoretically legal as long as its THC content is less than 0.2%.
Curcumin
Curcumin is the active ingredient of turmeric/ tumeric (Curcuma longa), a rhizomatous herbaceous perennial of the ginger family found in southern Asia. Studies have shown it to have anti-cancer properties, both preventative and therapeutic. It is an antioxidant, affects DNA regulation, and down -regulate s expression of COX-2, growth factors and cytokines. It also increases the effectiveness of drugs such as 5-FU and inhibits drug-induced toxicity. Research has shown it can retard the growth of tumour stem cells and inhibit VEGF.
Quercetin
Quercetin is one of the most abundant natural flavonoids, and is present in berries, apples, onions, broccoli, kale, red wine and tea. The daily recommended intake ranges from 5 to 500 mg, with the highest levels relating to fruit peel consumption. Its key biological functions are its antioxidant, anticarcinogenic, antiviral, anti inflammatory, psychostimulant, neuroprotective and cardioprotective properties. Like other phytoestrogens, it binds to alpha and beta oestrogen receptors. Research indicates that quercetin acts like a natural aromatase inhibitor and can also reverse tamoxifen resistance.
Wormwood
Wormwood is the Asian herb Artemisia absinthium. It is most commonly associated with the drink absinthe, and, as its common name implies, it was used to control gastro-intestinal parasites. The best-known active ingredient is thujone, while artemisinin is a bitter sesquiterpene used in malaria treatment. Artemisinin reacts with iron to form free radicals which can kill cells. Cancer cells require and take up a large amount of iron to proliferate and are therefore more susceptible to the cytotoxic effect of artemisinin than normal cells. In the laboratory, artemisinin inhibits proliferation and induces Gl cell cycle arrest of cultured MCF7 cells (an ER-positive human breast cancer cell line). It also selectively downregulates the transcript and protein levels of the CDK2 and CDK4 cyclin-dependent kinase genes.
Hyperbaric Oxygen Therapy (HBOT)
HBOT increases blood oxygen levels quickly to 100%, and thus pre-sensitises cancer cells to the effects of chemotherapy and radiotherapy, while also reducing the side effects from both. Studies have shown a synergistic effect on tumour cell death when combined with a keto genic diet and with Artemisia. There is also evidence that HBOT may help relieve arm lymphoedema in breast cancer survivors. Patients can be treated individually or in groups depending upon the size of the hyper baric chamber. Inside, the pure oxygen is administered at pressures 1.5 to 3 times normal atmospheric pressure. Treatment time is usually about 90 minutes.
Vitamin C
A variety of studies have shown that megadoses of i/v vitamin C are selectively toxic to cancer cells. It is thought that this is due to the release of hydrogen peroxide. Vitamin C also appears to strengthen colla gen in the surrounding peritumoural matrix. Added to these effects are stimulation of the immune system and improved analgesia. A systematic review of 37 studies published in 2014, found that vitamin C may lengthen time to first relapse, reduce tumour mass and improve survival in combination with chemotherapy. It may also improve quality of life by reducing chemotherapy toxicities. It can also be given as an oral, liposomal-bound preparation. The intravenous preparation is an expensive therapy and needs medical supervision.
SUPPLEMENTS
Vitamin B17
Amygdalin is the natural form and laetrile the synthetic version. The B17 molecule can produce hydrogen cyanide and this compound is released into the body’s tissues and targets and destroys mutated cells. It also stimulates the immune response. Amygdalin is found in >1,200 plant species, and is especially abundant in alfalfa, bamboo, beans, berries, yams, quince, cereals, pulses, nuts, flax and seeds and the pips of apples, lemons, limes, apricots and cherries. B17 injections are now illegal in the UK and most patients will use bitter apricot kernels which contain up to 3% amygdalin.
Vitamin 03
Vitamin D3 (VD3) is included in almost every nutritional programme for cancer patients. It is used to sup port immune function, prevent metastasis and promote cancer cell death. The authors have anecdotally noted that VD3 is commonly deficient in new patients with breast cancer. This notion is supported by research and meta-analysis. VD3 is induced naturally in the human body by sunlight and can be supplemented by oral preparations.
Berberine
Berberine is a yellow alkaloid compound found in European barberry, goldenseal, goldthread, Oregon grape, phellodendron and tree turmeric. It is known to activate adenosine monophosphate-activated protein kinase (AMPK). In vitro, it has been shown to retard breast cancer cell growth and induce apoptosis.
Medicinal Mushrooms
Medicinal mushrooms have been used for thousands of years, and act by increasing macrophage activity, by stimulating B and T cell production, by reducing chemo- and radiotherapy toxicity (especially alopecia and nausea) last-named effect is due to their linoleic acid content. The most commonly used mushrooms include coriolous, cordyceps, reishi, maitake, agaricus, phellinus and polyporus. Medicinal Mushrooms – a Clinical Guide by Martin Powell is a highly accessible introduction to this topic.
Breast Defend
This is a natural dietary supplement which has the ability to prevent breast cancer growth. It contains some of the most popular supplements including medicinal mushrooms and herbs. Research shows it can be especially effective against triple-negative breast cancer as well as in preventing breast cancer lung metastasis.
Mistletoe
Mistletoe (Viscum album) is a hemi-parasitic plant that has been widely used in medicine for hundreds of years. In the UK, it is prescribed as a subcutaneous injection ‘Iscador’, with the active ingredient being mistletoe lectin A (ML-A). This is a proven toxin with distinct effects on the immune system and tumour cells, including the triggering of necrosis and apoptosis. There have been a large number of studies looking at whether it can prolong overall survival in cancer patients, or reduce oncology side effects. Despite this, a recent large, retrospective ‘similar case’ study (2018) and two Cochrane Reviews (2019) have failed to confirm these claims. Nonetheless, Iscador remains a popular, prescribable therapy in Europe.
ANTI-HORMONAL THERAPY
Di-lndolemethane (DIM) and lndole-3-Carbinol (13C)
DIM is considered to be a stabilised version of its pre cursor BC and is found in cruciferous vegetables (the Brassica/cabbage family). The parent compound found there is Indole-3-glucosinolate (BG), which is converted to BC by myrosinase on cutting or light cooking of the vegetable. A mass of research now indicates that the latter has significant anti-breast cancer properties. DIM and BC act by denaturing oestradiol, regulating oestrogen receptor sites, converting highly-active oestrogen forms to less-toxic by-products and by initiating apoptosis (and thus is viewed by some as an alternative to tamoxifen).
Melatonin
People who have disturbed sleep patterns are known to develop more oestrogen-driven cancers, such as breast and prostate, because melatonin is an oestrogen regulator. Five lines of evidence suggest that melatonin works via epigenetic processes: it influences transcriptional activity of nuclear receptors involved in the regulation of breast cancer cell growth; it down regulates the expression of genes responsible for the local synthesis of aromatase; it inhibits telomerase activity; it modulates the cell cycle through the inhibition of cyclin D1 expression; and it influences the circadian rhythm of PER2 regulation. Melatonin can be bought over the counter in the Unite, d States but is banned in Europe. A plantderived version, Asphalia, as available as a capsule.
Astragalus
Astragalus or milk vetch (Astragalus membranaceous) has been used in traditional Chinese medicine for 2,000 years, and comes from the plant root which is similar to a garlic bulb. It contains antibacterial and anti-inflammatory phytonutrients, high levels of antioxidants, and has an ability to boost a weakened immune system. It is also a phytoestrogen. The active component attracts T cells and induces apoptosis. Astragalus helps the immune system differentiate between healthy and rogue cells, which in turn improves the effectiveness of radiotherapy and chemotherapy and reduces their complications.
LIFESTYLE
Exercise
Exercise helps prevent breast cancer, improves survival and reduces recurrence especially in post-menopausal women. Light to moderate workouts appear to be more effective than heavy, vigorous sessions. The WHO recommends a brisk walk for 40-60 minutes, where at some point you get puffed. This works by increasing tissue oxygenation. Moderate exercise of 150 minutes per week is estimated to reduce the incidence of breast cancer by up to 30%, and reduce mortality by an estimated 24%. Exercise can also help reduce stress, fatigue and memory impairment in breast cancer survivors. In the UK, about 3.5% of post-menopausal breast cancer cases have been attributed to lack of physical activity. Exercise-induced cancer prevention works by decreasing body fat with consequent reduction of oestrogen, leptin, insulin and IGF-1 levels, as well as by reducing inflammation and enhancing the immune system. Exercise also helps eliminate fat-stored endocrine disrupting chemicals such as pesticides, dioxins and polychlorinated biphenyls (PCBs). The effect of burning fat through exercise seems to be a more potent breast cancer prevention strategy than fat reduction by dieting alone.
Yoga
Yoga comprises advice for an ethical lifestyle, spiritual practice, physical activity, breathing exercises and meditation. Cramer and associates conducted a systematic review of the value of yoga in breast cancer patients, and identified 24 studies with a total of 2,166 participants. The results support the recommendation of yoga as a supportive intervention for improving quality of life, as well as reducing fatigue, sleep disturbances, depression and anxiety. These benefits may only last for a short time, and are seen more especially in patients during chemotherapy.
Dentistry
In meta-analysis, periodontitis was associated with a 22% increased risk of developing breast cancer. However, this could be contributed to by simultaneous confounding factors. Some patients will seek to have all their amalgam fillings (containing mercury) removed as part of their breast cancer therapy. There is little scientific evidence to support this, although the damaging effects of mercury on DNA are well documented.
OTHER
Black Salve
This ancient practice involves the external application of escharotic salves and pastes directly onto exophytic cancers. It is most commonly used for skin cancers and superficially lying breast cancers. Common ingredients include zinc chloride, bloodroot from Sanguinaria canadensis, nordihydrogauaretic acid from Larrea mexicana, a variety of roots (galangal and ginger), graviola leaf, bitter melon seed and glycerol. Black salve seems to differentiate between normal and cancerous tissue, and destroys the protein barrier which surrounds a tumour thus allowing the immune system access. A similar process was harnessed in skin cancer surgery by Frederick Mohs. His fixative paste contained bloodroot, zinc chloride and stibnite. He discovered he could remove malignancies with complete microscopic control if the borders between the neoplasms were clearly demarcated. The treatment process can be prolonged and incapacitating. There is a risk of infection, while pain control can be a major issue, causing patients to abandon the process midway. It is generally recommended that only one tumour should be treated at a time.
Homeopathy
Homoeopathy is a hotly debated and divisive concept whereby therapeutic effects are claimed to occur after administration of heavily diluted chemicals. Most scientific evaluations of homeopathy fail to show any benefit of this so-called nano-particle therapy and at best attribute any claimed benefit to a ‘placebo’ effect. Nonetheless, there are some interesting observations in breast cancer. A Cochrane Review by Kassab et al. (2009) of the value of homoeopathy in alleviating the side effects of cancer therapy found that data supported the use of topical calendula in preventing radiationinduced dermatitis and Traumeel S mouthwash for chemotherapy-induced stomatitis. Hydrastis canadensis (goldenseal) displays selective toxicity against MCF7 cells in vitro, and Arnica montana reduces seroma and haematoma formation after mastectomy.
Hyperthermia
Hyperthermia is the use of heat to kill, weaken or sensitise cancer cells. It comes in two forms: whole-body hyperthermia, which has been shown to improve the effectiveness of chemo- and radiotherapy, and localised hyperthermia as is used in isolated limb perfusion or intra-arterial chemotherapy. Hyperthermia is defined as elevating tumour temperature to between 40 and 45°C for one hour. It can be delivered by ultrasound, microwave, radiofrequency, infrared, laser or magnetic induction devices including magnetic iron oxide nanoparticles and alternating magnetic fields. There is now a considerable body of published data that shows that the combination of hyperthermia and radiotherapy for locally advanced or locally recurrent breast cancer can provide sustainable palliative tumour control with low toxicity. In addition, through its abscopal effect (immune stimulation at the treatment site, causing an effect at a distant site), it can cause shrinkage of untreated distant metastases. The principle of hyperthermia dates back to Ancient Egyptian and Greek medicine and formed the basis for Coley’s toxins (controlled injection of dead bacteria).
Re-Purposed Drugs
This concept promotes the use of pre-existing drugs for new uses in the oncological arena. Researchers in this field are particularly keen to exploit cheap, non-toxic drugs which target the microclimate of the tumour/ mesenchyme interface. This approach helps reduce drug costs and drug development time. Examples of promising drugs include metformin, cimetidine, aspirin, sodium bicarbonate, clomipramine, promethazine, mebendazole, naltrexone, itraconazole, isotretinoin and even thalidomide. The aspirin story is the most compelling one in breast cancer, with a 10% reduction in relative risk of developing the disease and a suggestion of improved survival in post-menopausal ER-positive cases.
IMAGING
Some patients will have concerns about receiving worrying dosages of ionising radiation from imaging procedures required to diagnose, treat and monitor their breast cancer. A two-view bilateral mammogram will cause exposure to 0.4 mSv, which is well below the average annual exposure of 2.7 mSv in the UK and 6.9 mSv in Cornwall. For patients unwilling to accept this dosage, ultrasound, MRI and even thermography have a role, but the shortcomings and cost of these alternatives need to be stressed. Cross-sectional imaging with MRI rather than CT or radionuclide scans is also a useful back-up. The key is to listen to the patients’ concerns and inform and accommodate compromise where possible.
BLOOD TESTS
Some patients will come armed with a variety of blood tests that they have had done outside the healthcare system. Many of these will have been carried out in European-based laboratories. Quite often the printed out results contain huge amounts of potentially unvalidated information regarding circulating cellular waste products, DNA fragments and circulating cells which are then bio-tested to help predict the most effective therapies. Though much derided, these tests could be imagined as the precursors of the ‘New Age’ Liquid Biopsy!
CONCLUSION
With the number of breast cancer patients exploring alternative therapies ever increasing, we hope that this chapter has introduced the attending specialist with sufficient information on the topic to enable them to open a meaningful discussion with their patient. Specialists should also be aware that finding the cancer seems to not infrequently coincide with a serious life event. This possible causal relationship should be explored. It should be noted that charities and patient groups are crucial in helping support breast cancer patients exploring and/or adopting alternative pathways. Above all, as breast cancer patients and their attending specialists have a potentially long-term association, do not underestimate the healing potential of a skilled, specialised and supportive doctor who, without prejudice, shows a willingness to collaborate with their patients in the interest of their mutually desired goal.
ACKNOWLEDGEMENTS
The authors would like to thank Chris Woollams (Founder of Cancer Active) and Jane Mclelland (for repurposed drug in formation).
Co-Author
Jessica Richards is a self-treated patient diagnosed with biopsy-proven sentinel node positive breast cancer in 2007. The primary was never removed medically but treated with Black Salve.