Ask the Expert: Integrative therapies

For hundreds or even thousands of years, people with cancer have relied on complementary therapies to manage side effects of cancer and its treatments. These therapies can involve nutrition, mind-body practices, artistic expression and certain forms of exercise. Only in the last few decades have these methods, now collectively called integrative therapies, become an accepted part of mainstream Western medical care.

Dwight L. McKee, MD presented at a November 2016 Living Beyond Breast Cancer program called Treating the Whole You: Integrative Care and Breast Cancer. More audience questions were submitted than could be answered during the program, so Dr. McKee agreed to answer some of those questions here. He also took new questions from you about integrative therapies, from supplements to take and foods to avoid, to how mindfulness and self-expression can help you feel better during cancer treatment, and more.

Are certain foods better depending on the type of breast cancer you have, like estrogen receptor-positive or triple-negative? Are any foods bad based on the subtype?

The best types of foods for estrogen-sensitive cancers are crucifers (broccoli, cauliflower, bok choy etc.) These foods contain phytochemicals that have been shown to help detox the body of “bad” estrogen. I highly recommend you watch this TED talk. I think you will find it very helpful.

Low-fat diets, such as the Ornish diet, have been shown to decrease the risk of triple-negative breast cancer.

What supplements, herbs and foods do researchers suspect may be problematic for people in treatment? Are there things we should avoid, other than no-brainers like artificial sweeteners and colors?

Fish oil shouldn’t be taken between the day before and the day after chemotherapy treatments.

There is early evidence that taking berberine, quercetin, curcumin or resveratrol at the same time as chemotherapy treatment with paclitaxel (Taxol) may affect how well paclitaxel works. Avoiding supplements the day before, day of, and day after chemotherapy is likely to avoid interactions, but many oncologists are not comfortable with supplements being used at all during chemotherapy.

St. John’s wort should not be taken with certain chemotherapy medicines. Ask your doctor about which whether the chemotherapy you're on might interact with St. John's wort.

Most herb-nutrient-drug interactions are theoretical. Still, when chemotherapy or radiation are being given for early-stage breast cancer, its best to be more conservative about these issues. When treatment is being given for metastatic breast cancer, it's reasonable to worry much less about theoretical herb-nutrient-drug interactions.

I’ve heard turmeric lowers the risk of breast cancer recurrence. Does research support this?

What we know is that people who consume turmeric regularly as part of their diet have lower rates of breast cancer (as well as lung, prostate and colon cancers), but this does not prove cause and effect. Research studies done at MD Anderson Cancer Center, in Houston, by Dr. Bharat Aggarwal and his team have shown that both turmeric, and its often-used purified component, called curcumin, are active against breast cancer cells in pre-clinical studies (tests in tissue culture, and in animal models where human breast cancer has been established in the animal). Many registered phase I/II clinical trials designed to investigate the effectiveness of curcumin alone or with first-line treatment in patients with breast, prostate, pancreatic, lung, or colorectal cancer are under way.

An excellent way to consume turmeric (which is about 3 percent curcumin, but contains many other active compounds), is the way its traditionally been used in India for many centuries: dissolving the yellow powder by heating it in coconut oil, then adding black pepper to taste, and using this mixture as a base for stir fries, soups and stews. Black pepper contains a component called piperine, which causes much more of the curcumin in turmeric to be absorbed.

Is it safe to take turmeric while on tamoxifen?

Based on what I have read, yes. With tamoxifen, if your oncologist is concerned about potential interactions with herbs, nutrients, or diet, he or she can order an "endoxifen" test that will give you more information.

Nutrients that protect against side effects of tamoxifen include CoQ10, riboflavin (vitamin B2) and niacinamide (vitamin B3).

What is the appropriate dose of melatonin to help with sleeping problems?

Start with 1 to 3 milligrams. If that works, there is no need to take more. But if it doesn’t help, you can increase the dose to 5 or 10 milligrams. If you feel more groggy than usual the next day, decrease the dose.

What dose of curcumin do you recommend?

Three grams a day of Meriva or BCM-95 curcumin (two curcumin products that are available for sale) is the suggested dose for people with cancer.

I was treated for breast cancer with chemotherapy in 2013. My thyroid is working normally, but I cannot get rid of the weight I gained despite exercise and a strict diet. Any tips on how to lose weight?

This may be related to chemotherapy injuring parts of cells called mitochondria. The best way to bring about production of new and healthy mitochondria is challenging exercise, such as working with a personal trainer or physical therapist to keep challenging yourself, but avoiding injury.

You might also try a ketogenic diet, with a 5:1 ratio of healthy fats (avocados, olives, olive oil, coconut milk, oil and/or medium chain triglycerides (purified from coconut oil); to protein, with many non-starchy vegetables, particularly of the cruciferous family, and no more than 20-50 grams of total carbohydrates. You can use urine test strips to detect ketones (which are present when the body is burning fat for energy). Taking exogenous ketones as supplements can be quite supportive, particularly in reducing carbohydrate cravings in the first week of the diet.

Can herbs, supplements, or high antioxidant foods "feed" the growth of the cancer?

There have been some pre-clinical experiments (done on tissue cultures or animals, not people) that have shown stimulation of cancer by specific isolated supplements such as N-acetyl cysteine. Such studies cannot be generalized to entire classes of nutrients such as antioxidants, and there is no evidence of harm from antioxidants of any sort in people being treated for cancer. In general, complex mixtures of nutrients are more likely to be helpful  than taking large amounts of a small number of nutrients.

Where are the best places to buy supplements? Are there certain brands or ingredients that should be avoided?

It's best if you can find a knowledgeable person in the supplement section of a local health food store who has been involved in the supplement area for many years, and gets regular feedback from customers about their experience with supplements that he or she has recommended. There have been documented instances of counterfeiting of reliable brands on Amazon and other large internet retailers/wholesalers.

Is it OK for someone who has had breast cancer to drink hibiscus tea?

Yes. It's also good for high blood pressure.

What supplements can help me with joint and bone pain caused by an aromatase inhibitor?

Most important is getting enough vitamin D. For some people that may be 5,000 international units per day, but some may need more. Talk to your doctor about regular testing of your vitamin D levels.

You can also try 5-20 grams per day of methylsulfonylmethane (MSM). Start on the lower end of that scale and work up to see if there is an effect. It's best to split the dose between morning and mid-day. Too much MSM late in the day can interfere with sleep.

Taking 1-2 tablespoons a day of tart cherry concentrate may help some people.

Anti-inflammatory enzymes such as bromelain are also sometimes helpful. Here is a good article on the subject.

What supplements can help with fatigue?

The biggest help for cancer and cancer treatment-related fatigue is exercise. If you notice exercise makes your fatigue worse, then you have to start with a very small amount of exercise, and slowly increase it. Increased fatigue the next day indicates the “dose” of exercise was too high, so reduce it again, and escalate it more slowly.

Taking 100-250 milligrams per day of a supplement called nicotinamide-riboside is also sometimes helpful. Thorne Research is a reliable brand, as is Elysium Health's Basis (which combines it with pterostilbene, a cousin of resveratrol).

Fatigue in relationship to cancer and cancer treatment is a complex problem, and I suggest working with a nutritionist, an herbalist experienced in working with people who have had cancer, or both. I would avoid supplements like DHEA and pregnenalone if you've had an estrogen receptor-positive breast cancer, as these hormones can be made into many other hormones by the body, estrogen being one of the possibilities.

Should any foods, supplements or medicines be avoided during radiation therapy?

Some radiation oncologists tell patients not to take any antioxidants, and some even tell their patients to avoid antioxidant-rich foods such as blueberries or kale. This belief is based on the understanding that the major way that radiation therapy damages and kills malignant cells is by creating oxygen free radicals, which do the damage. But there is NO clinical evidence that any sort of diet or antioxidant supplements interfere with the anti-tumor effects of radiotherapy.

Its best to find a practitioner experienced in counseling patients regarding diet and supplements during and after cancer therapy. There are certain botanicals, such as artemisinin (from the herb Artemisia annua, also known as sweet Annie), that are powerful radiation sensitizers, and too large a dose taken regularly during radiotherapy can increase radiation toxicity to normal tissues. But botanicals such as this are not something most patients would use on their own.

What is your opinion about people with cancer taking metformin or using other approaches that lower glucose in the body? Is there evidence it treats the cancer?

There is quite a bit of evidence suggesting metformin is of benefit in many cancer types, and some doctors are prescribing it for people with cancer who are not diabetic. But it hasn’t been proven in a human clinical trial. Clinical trials are expensive and metformin is an old medicine whose patent expired long ago, so such a clinical trial would have to be sponsored by the National Cancer Institute or some other organization not interested in making enough of a profit from the medicine to make up for the cost of the trial.

How can mindfulness or meditation help me deal with cancer treatment? Do you have any tips on how to make this a part of my life?

There have been a number of studies on mindfulness based interventions (MBI) done with cancer patients that suggest daily practice of mindfulness leads to reduced stress and improved quality of life. But there are few studies that ask whether it reduces the risk of recurrence or increases survival in people with cancer.

Accumulating evidence suggests participation in an MBI contributes to reductions in psychological distress, sleep disturbance and fatigue, and promotes personal growth in areas such as quality of life and spirituality. MBIs may also influence the immune system and nervous system activity, though it remains unclear whether these biological changes translate to clinically important health benefits.

One of the best ways to learn mindfulness and mindfulness-based meditation is to attend a course. Many cancer centers now offer these to their patients. Then you can set aside certain times in the day (many prefer early morning or evening) to practice. You can also take a few moments (especially when you're feeling stressed) to practice for just a minute or two throughout the day.

It seems reasonable that reducing stress, improving immune function, and just being happier and calmer is likely to translate into reduced risk of recurrence and improved longterm survival in breast and many other forms of cancer. But we don't yet have solid proof of this from randomized clinical trials.