In terms of personalized mainstream treatment, it is likely that the cancer with the most options today is breast cancer. Breast cancer has gone from being a late diagnosis and often fatal disease to one that can be managed to a large extent as a “chronic disease” over many years, even in the presence of metastases. Breast cancer diagnostic and treatment advances are all due to a very robust research effort internationally which has led to very personalized treatment guidelines. There are a number of good guidelines, but the ones that are updated most often and the most patient friendly for review are provided by the National Comprehensive Cancer Network (NCCN), an independent organization of cancer centers with a mission as noted below. I find this organization produces prudent comprehensive guidelines that are not beholden to external pressures from any third party, such as the government or pharmaceutical houses. They convene, review and report the best up-to-date scientific evidence for every component of breast cancer treatment. Our mission, as an alliance of leading cancer centers devoted to patient care, research, and education, is to improve the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. The NCCN site is very big and comprehensive but can be a little hard to navigate, so I have provided focused links for you to review and some commentary beyond that. The following are specific for stages and open up as interactive electronic books for free, but can also be purchased in hard copy for a nominal price on Amazon. You will also see that breast cancer is subcategorized not just by “stage” and “grade” but also by presence or absence of hormone or growth factor dependence, and by pre-menopausal or post-menopausal status. Most breast cancers are either hormone receptor or HER-2 positive, or have both. This allows “targeted” molecular therapy for patient either by blocking hormonal growth input at the estrogen or progesterone receptor on the cell surface or, in the case of HER-2 positivity, biological drugs like Trastuzumab can bind to the HER2 receptor and either prevent it from sending growth signals to the nucleus of the cell or by binding it and “tagging” the cell for destruction by the immune system. Trastuzumab is responsible for a major advance in survival in many patients, and better targeted agents are constantly being developed. Learn more about the basics of tumor biology and receptors by clicking HERE. Triple negative breast cancer, which is the most difficult to treat, has no dependence on hormones or currently known growth factors. No, or very few, targetable receptors exist on or in these tumor cells. This is so-called Triple Negative Breast Cancer for which you can find more information by clicking HERE.
You can certainly also rely on other guidelines, like those from the American Association for Clinical Oncology (ASCO), but they are really written for physicians and focus on specific issues rather than comprehensive management. ASCO is probably the largest meeting every year where cutting edge research is presented, so it is prudent to watch what comes up on their site. The following is a set of twenty-five very informative videos from the City of Hope Cancer Center which offers a lot, but not everyone is close to that center. Highly skilled surgeons and oncologists can be found at a multitude of centers across the United States and abroad. If you feel that the doctors and/or center you are currently in does not seem to jive with the guidelines above, you should consider seeking a second opinion at a larger academic or private high volume center that sees a lot of breast cancer. If you are a Kaiser Permanente member, there are many highly rated high volume centers and oncologists to choose from. The physicians there may simply confirm that what has been recommended is reasonable or you may have to consider other options even if it is treatment at a longer distance from home. The following videos keep playing in sequence or you can choose the ones you would like to view by using the “PLAYLIST” menu in the upper left of the video screen.
Complementary Breast Cancer Support
When it comes to complementary support for symptom control, breast cancer patients and survivors are arguably the biggest consumers of this much needed extension to the disease treatment modalities discussed in the guidelines above. There is really no restriction to most aspects of complementary support, including acupuncture and acupressure for pain and nausea. Mind body techniques can only help and massage, music and laugh therapy can hold you together in ways that go way beyond the “feel better” benefits. I’m talking about psychoneuroimmunology and related disciplines which support not just your psyche, but also your cancer fighting immune system. Lest you think this is of marginal benefit, UCLA has devoted attention to this at the Cousins Center for Psychoneuroimmunology. The Society for Integrative Oncology produced a set of guidelines for complementary therapies in breast cancer, which can be viewed HERE.
Natural Integrative Nutritional and Botanical Breast Cancer Support
As in any disease, an ounce of prevention is worth a pound (or, in the case of cancer, tons) of cure. Breast cancer, is largely due to a complex interplay of environmental impact on genetic expression via epigenetic control. What this means is that you are what you eat, drink, breathe and are exposed to. Some of use have bullet proof genes which can keep us away from cancer or other diseases no matter how bad our lifestyle choices, but most of us do not have that luxury. At the same time, the good news is that the vast majority of breast cancers are not purely genetic to the point that you are preordained and doomed from birth. You are in control in terms of prevention.
Integrative Prevention: A Much Needed Paradigm
Prevention of cancer can be primary, secondary and tertiary. Primary prevention is that set of lifestyle choices that keep us away from cancer in the first place. It means selecting the very best options known to the human race which are proven or scientifically plausible in keeping bad genes silenced and good anti-cancer genes activated. It also means using the best means available to screen for cancer. Secondary prevention means amping up these good lifestyle choice efforts when you know you have pre-cancerous changes or even early indolent slow growing cancer. Tertiary prevention is what you do to try to get at the root cause of why you got breast cancer to begin with and then focus on correcting that to prevent recurrence. Of the three, tertiary prevention is the most neglected. Evolving 21st century sciences like epigenetics, nutrigenomics, and metabolomics coupled with the developing mainstream theory of “cancer stem cells” is what provides a lot of scientific fuel to the concept of primary, secondary and tertiary natural integrative prevention of breast cancer (as well as other cancers). There are textbooks written on these topics and reams of scientific articles, but the links provided to Wikipedia should give you a strong background (if not overwhelm) and remind you that cancer and its prevention and treatment are an extremely complex set of topics. I hope this information here makes it understandable and why it relates to natural support in such a way that scientifically supports these recommendations. Central to the natural integrative options for breast and other cancers is the cancer stem cell and how we can affect it with epigenetics and, more specifically, nutrigenomics. The following video is just one example of nutrigenomic influence on stem cells. Here we look at the sulphorafanes found in broccoli. There are many other examples and probably work synergistically within a solid whole food anti-cancer anti-inflammatory anti-oxidant diet.
It is true that many natural support recommendations are based on basic science or epidemiologic observations, which does not absolutely prove that they will work in everyone. Only randomized clinical trials can do that from a purely scientific and statistical point of view. However, it is impossible to accurately randomize some interventions (e.g. whole diet changes), and it is unethical to do so in other situations (e.g. Pap smear prevention of cervical cancer was never proven in clinical trials but no one would suggest we do that today). In fact, only about 30% of what mainstream oncology recommends in breast cancer is based on high level clinical trials proof. So, a scientifically plausible intervention which is relatively low risk is hard to justify neglecting. The higher the risk of harm the more this argument falls apart, but we are heading in this direction in mainstream oncology as well. New “targeted therapy” advances are accelerating to the point that it will be impossible to perform clinical trials fast enough and control for interactions with all other medications. It is a dilemma which mainstream medicine is looking to fix with computer modeling and other scientific techniques that are beyond this topic. However, regarding integrative natural support, scientific plausibility or convincing epidemiologic observation makes the recommendations noted here far more credible than the tons of charlatan based “alternative” junk out there robbing people of money as well as life itself. In some cases, there is in fact clinical trial data, albeit often very rudimentary. However, it is worth repeating, low risk intervention in the absence of a better “proven” alternative is a reasonable consideration, especially in the setting of tertiary prevention.
Integrative Nutritional & Botanical Breast Cancer Intervention Controversies
In general it is easier to recommend nutritional and botanical interventions in primary, secondary and tertiary prevention than it is during therapy. This concern is based on very good reasons, mostly based on safety and possibility of interfering with mainstream therapy. While almost all oncologists would recommend lifestyle and screening based primary prevention, fewer would recommend all aspect of secondary integrative prevention and only those “in-the-know” recommend much in the way of tertiary prevention. The degree and scope of these recommendations vary, but they fall in a fairly broad range of oncologist acceptance. However, when anything is discussed as an integrative nutritional or botanical intervention concurrent with treatment most oncologists will balk beyond simple dietary changes. The truth is that most of this is a theoretical and somewhat emotional argument as there is no data to contradict integrative interventions, but it is also true that absolute proof of safety is lacking. It can quickly become a circular argument. The biggest areas of controversy are centered on the use of anti-oxidants and plant estrogens (phyto-estrogens) during chemo or radiation therapy. As far as anti-oxidants are concerned, most oncologists argue that if we are using pro-oxidant chemotherapy and radiation therapy then anti-oxidants might interfere by protecting cancer cells. The published research data does not support this claim but it does not unequivocally disprove it either. Those that are proponents of their use state that anti-oxidants will only or highly preferentially protect normal tissues, thereby lowering toxicity of chemo or radiation. In fact, synthetic anti-oxidants are sometimes used to reduce cardiac toxicity when Adriamycin is administered without proven reduction in efficacy. Similarly, synthetic anti-oxidants are selectively used to protect normal tissues during head and neck radiation. Another example is the use of an anti-oxidant compound called MESNA to prevent bladder damage when using Ifosfamide. It does not make complete sense that one of these would be recommended while an antioxidant supplement would be prohibited, but the debate continues. Generally, more oncologists would support selective use of anti-oxidants in situations of salvage chemotherapy where cure is no longer possible, in favor of quality of life factors. On the other extreme are oncologists who do not even want patients to consume a lot of dietary anti-oxidants at any point. In my opinion, until we have clear safety data, when initial curative intent treatment is being used, it is probably prudent to stay away from high dose supplement anti-oxidants. However, it is reaching too far to tell patients to avoid an anti-cancer anti-oxidant anti-inflammatory diet during treatment. So, all I can say is, talk with your oncologist and based on mutual risk/benefit discussion, make a decision. Next, what about phyto-estrogens or any estrogens for that matter? This depends somewhat on what the estrogen receptor status is, but not completely. If a tumor is estrogen receptor (ER) “negative” does not always mean there are zero estrogen receptors. It just means that there are relatively few, but this is not precise in most cases. So a ER negative tumor does not have enough receptors to effectively fight the cancer using estrogen blockers, but on the other hand even some receptors will latch on to estrogen and possibly slowly fuel the growth. So, it would seem reasonable to avoid all estrogen if possible. Keep in mind that estrogen can come from ovaries (unless blocked by drugs) or from fat cell conversion. In an ER tumor that blockade is what is done as “targeted” therapy. In an ER- tumor this is not done, but adding more estrogen externally is not prudent because it is possible that some lower level receptors actually exist. One way to reduce estrogen load naturally is weight loss, which reduces the amount of fat available for hormone conversion to estrogen. Exercise is a prudent lifestyle modification for all the reasons mentioned as well as general health benefit. What about phyto-estrogens in particular? Although the same logic would seem to apply, plant estrogens are very weak in binding to estrogen receptors. We also know from some, but not all, epidemiologic studies that maybe phytoestrogen isoflavones are protective against breast cancer. Breast cancer incidence in the United States has been 4–7 times that in Asia, and isoflavone consumption in the United States is <1% of that in Asia. Intake in the US is <1mg/day , compared to 20 to 80 mg/d in Asian countries. This may sound convincing but is the reason epidemiology does not prove cause and effect. High phytoestrogen isoflavone soy consumption in Asia is only one of many differences in lifestyle compared with the US, any one of which might be more important. You would have to drink gallons of soy milk (or take a high dose supplement) to achieve the 20-80mg/day intake seen in Asia, but read on as this may not be a good idea. To explain the possible beneficial effect of soy this is what happens at the molecular level of the estrogen receptor. Phytoestrogens can act as an “agonist”, activating the receptor, which is not good. But it can also act as a “antagonist” by binding to the receptor and making the receptor unavailable to bind to stronger estrogens, like the ones from ovarian or fat sources. How much of which action will happen in any individual is unknown, and it actually gets more complicated. There are two types of estrogen receptor, ER-α and ER-β. ER-β is the preferred binding site of phytoestrogens and may have anti-proliferative effects, opposing the proliferative effects when ER-α is bound by estrogen. The interaction gets pretty complex, and no one knows if taking more has a bigger effect and on what receptor. Based on laboratory studies, this is probably very different from tumor to tumor. This is why it is not prudent to get carried away with taking large amounts of phytoestrogens which can occur in “pharmacologically” packaged high dose 50mg/day supplements. Vendors of these supplement products assert that the phytoestrogens will exert a purely anti-cancer antagonist role, but this strategy of “more is better” is a dangerous guessing game. Using this high dose supplement strategy is akin to playing Russian roulette with your life.
Breast cancer treatment is extremely complicated these days, but that is awesome because this means it is actually getting more and more targeted to individual needs. Guidelines for mainstream therapy are evolving rapidly as newer biological agents that have precise molecular targets are developed. It is possible that breast cancer will be the model that eliminates chemo from treatment first, before other cancers. It is prudent to be treated where the oncologists are up-to-date on the latest science based guidelines. As far as complementary and integrative support during treatment the following specific checklist should be considered, along with the general advice about complementary modalities, nutrition and supplement use found throughout this website. This list focuses on time of treatment. For prevention, including tertiary prevention, other than the controversy about estrogens (especially in ER situations), aggressive prudent anti-cancer lifestyle choices discussed on this site fully apply to breast cancer. Triple negative breast cancer is discussed HERE, and some of those specific tertiary measures are reasonable in any variant of breast cancer.
- Stress reduction, sleep and mind body techniques
- Acupuncture and acupressure as needed
- Anti-oxidant anti-inflammatory diet such as “old school” Mediterranean Diet, focusing mostly on whole plant based foods
- Avoid higher dose supplement “pharmacologic dose” anti-oxidants
- Moderate dietary soy intake, after review with your oncologist
- Exercise, moderate “burst training” based as well as resistance training at least three times per week
- Consider proteolytic plant enzymes (bromelaine and papain) after node dissection (discussed elsewhere)
- ALWAYS discuss what you are doing and taking with your oncologist and pharmacist to ensure safety