Healing after breast cancer treatment.
Subject: Postmenopausal women (Drug therapy)
Breast cancer (Drug therapy)
Breast cancer (Development and progression)
Breast cancer (Patient outcomes)
Author: MacDonald, Barbara
Pub Date: 02/01/2012
Publication: Name: Townsend Letter Publisher: The Townsend Letter Group Audience: General; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 The Townsend Letter Group ISSN: 1940-5464
Issue: Date: Feb-March, 2012 Source Issue: 343-344
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 282825222
Full Text: Breast cancer is a "survivable disease" for most women.(1) The relative survival rates are 89% at 5 years, 82% at 10 years, and 77% at 15 years. (2) Most are for postmenopausal women whose tumors are node-negative, estrogen-receptor positive (ER + ), and HER2/neu-negative. (3-6) After cancer patients have survived 5 years, they are thought to be cancer free. However, breast cancer is a late-recurring disease. Twenty percent of women who were disease-free 5 years posttreatment are still at risk of a recurrence at 10 years. (7) Most of the late-recurring cases had estrogen-receptor positive tumors and their oral hormone-modifying medication tenure is only 5 years. This leaves a significant gap in the conventional treatment of breast cancer.

After conventional cancer treatment removes the manifestation of the body's underlying state of imbalance, the process of facilitating healing begins, in order to help restore health and hopefully remain cancer free. I propose that naturopathic medicine can play a role in reducing this late recurrence risk by treating patients with basic complementary and individually designed, constitutional methods. I review the roles that naturopathic physicians play in helping breast cancer survivors to heal.

Naturopathic Care After Conventional Treatment for Breast Cancer

To summarize the roles that naturopathic physicians play in support of those healing after breast cancer treatment, I describe three broad categories: complementary care, basic naturopathic care, and individualized constitutional care (Table1).

Complementary Care

Supporting breast cancer patients recovering from surgery, chemotherapy and/or radiation is the first of role that we play after treatment ends. Next, manage lingering treatment-related side effects and potential toxicities. This is reviewed with Dr. Kelly Jennings in our textbook, The Breast Cancer Companion: A Complementary Care Manual. (8)

Next, support patients taking hormone-modifying medications. We have many tools for limiting symptoms related to menopause, arthralgia, myalgia, and so on. (9) Help monitor them for endometrial, osteoporotic, hepatic, clotting, lipid changes, and other possible signs of toxicity. (10) Help patients avoid taking contraindicated supplements and botanicals. In addition, offer agents found to be synergistic with selective estrogen-receptor modulator (SERM) and aromatase inhibitor (Al) medications. See Table 2 (p. 78) for a summary of contraindications and synergistic agents.

Basic Naturopathic Care

In addition to complementary care during conventional treatment, naturopathic physicians offer numerous methods for helping patients afterwards. What I am calling basic naturopathic care is a posttreatment naturopathic template.

First, educate patients on the evidence-based lifestyle modifications found to help prevent recurrence by up to 50%. Previously, we relied on primary prevention studies. Now we have a small body of data that can be used to empower patients to optimize their lifestyle in order to reduce risk of recurrence. Conflicting dietary intervention trials prove confusing. Some studies do, however, support recommending a diet that is high in fiber, vegetables, fruit, and soy and calories from fat as low as 15%. See Table 3 (p.80), for details and references. There seems to be consensus, however, about the therapeutic value of exercise, achieving optimal body mass index, limiting alcohol intake and drinking green tea. Studies on preventing recurrence with an empowering lifestyle are detailed in Table 3.

Many nutritional supplements and botanicals recommended in breast cancer treatment plans are based on primary prevention studies and warrant consideration such as turmeric, mushroom extracts, melatonin, higher dosages of CoQ 10. These agents are more thoroughly reviewed and are referenced in The Breast Cancer Companion as well as The Definitive Guide to Cancer. (11), (12)

There are several agents, however, that have prevention of recurrence data in animals and humans. Taking vitamin supplements, vitamin C and E, CoQ10 with antioxidants, drinking green tea all have inverse associations with breast cancer recurrence. Taking Coriolus versicolor mushroom extracts, melatonin, and black cohosh were also found to increase survivorship among specific subsets of breast cancer survivors. See Table 4 (p. 81) for studies, references, and an associated basic treatment plan.

In review, there are important roles that the naturopathic physicians offer patients after conventional breast cancer treatment. The aim of complementary care is to assist patients in recovery and healing after conventional oncologic therapies and to resolve residual side effects. In addition, basic naturopathic guidelines provide a template for helping patients to reduce recurrence risk with both lifestyle medications and evidence-based natural therapeutics.

Individualized, Constitutional Treatment of People Who Have Had Breast Cancer

Overview

Conventional approaches to treating breast cancer are like the Coast Guard arresting a speedboat. This is especially important in cases of aggressive or late-stage disease. Naturopathic approaches are like a sailboat harnessing the natural power of the wind to guide the boat to safety. Adding these approaches is recommended, especially for the majority of women who may develop late-recurring breast cancer. I propose that together, we may be able to arrest the manifestation of this disease and guide the patient toward healing.

Naturopathic foundational principles include treating the whole person, not treating cancer, treating the underlying cause of an illness, not the symptom, using the healing power of nature, and removing obstacles to a cure. To inspire transformational healing, first identify the patient's constitutional factors.

There are nonmodifiable risk factors that many patients share, such as being female and aging. (13) However, many patients have no other risk factors like obesity, smoking, DES exposure, excessive alcohol consumption, gene mutations, or family history. Other women who do have breast cancer risk factors never get it. (14) The cause in many cases is multifactorial. Consider a combination of factors like genomics, unfortunately timed toxic exposures, individual constitution and lifestyle factors.

Over the 14 years that I have treated women with breast cancer, I have noted that there are common constitutional factors that need to be treated in order for transformational healing to occur. For simplicity's sake, I have grouped them into three broad categories; detoxification, inflammation, and stress response.

To identify an individual's constitutional imbalance(s), take a thorough medical history, environmental exposure history, psychological/social history, and family history. (15) You may include a Chinese Medical history. Perform a traditional and nutritional physical examination, Chinese Medicine pulse, tongue, and energy evaluation if desired. From the clues presented, run appropriate tests. Then methodically treat each layer of dysfunction using naturopathic foundation principles (Table 1).

Detoxification

Detoxification refers to the risk of malignant transformation from breast tissue toxicity in an individual whose genome inhibits metabolism and elimination of toxins. (16) Exposure is most concerning at times of rapid cell division such as in utero or during puberty.

To evaluate the hypothesis that detoxification issues play at least a partial role in the etiology of a patient's breast cancer, perform single nucleotide polymorphism (SNP) testing. (17), (18) Evaluate: (1) hormone metabol ism; (2) detoxification of specific environmental toxins; (3) medication metabolism. Consider testing sufficiency of amino acids used in detoxification as wed as a urine organic acids test to evaluate hepatic stress.

Subsequent to identifying SNPs related to hormone metabolism, order an estrogen metabolism test of the ratio of 2-hydroxy estrone to 16-alpha hydroxyestrone. Higher ratios are associated with reduced risk of breast cancer, especially in those with ER-negative tumors and if premenopausal. (19-21) If patients are taking hormone-modifying medications, consider treating issues of estrogen metabolism with diet alone. Consider a diet low in animal protein, or vegan plus low-toxin fish, ground flaxseed meal (especially in those with catechol-O-methyltransferase polymorphism, or COMT SNP), organic whole soy foods, cruciferous vegetables, and green and white tea. (22-26) If they are not on hormone-modifying drugs, consider diindolylmethane (DIM) and test estrogen metabolism quarterly until therapeutic dose is achieved. (27)

if a patient has SNPs that affect detoxification of solvents or polyaromatic hydrocarbons and their history indicates, consider testing specific toxin load. (28) If they are deficient in amino acids of detoxification and/or have hepatic stress, consider replenishing amino acids during a six-week toxin-specific cleanse. Follow with quarterly 10-day cleansing.

If a patient has a null GSTM SNP and history indicates, cautiously consider oral or IV-chelated toxic metal test and treatment. It is theoretically possible that liberating carcinogens may increase vulnerability to mutation.

Inflammation

For some, the constitutional imbalance is related to inflammation. This refers to the risk of malignant cellular transformation of breast tissue resulting from states of systemic, tissue, and/or intracellular inflammation. Research supports the potential role of inflammation as a factor that may contribute to breast cancer occurrence. (29) In 2009, the Journal of Clinical Oncology reported "some of the most persuasive evidence yet that chronic inflammation might increase the risk of breast cancer recurrence." (30) Further evidence points to a negative immune shift from TH1 to TH2 dominance that contributes. (31)

When considering treatment for chronic inflammation, lookforathickly coated or scalloped tongue, slippery pulse, edema, overweight. Listen for a history of bloating, diarrhea, constipation, digestive infections, congestion, allergies, discharges, itching, phlegm, rash, pain, and so on. Research studies have identified blood markers of inflammation that have been correlated to breast cancer incidence, recurrence, and prognosis: CRP, circulating acute phase proteins, interleukin 6, VEGF, TH2 immune activation complexes, D-dimer, and so on. (32-38)

Evaluate and treat thyroid dysfunction. Autoimmune thyroid disorders account, to a large extent, for the increased prevalence of thyroid disorders among breast cancer patients. (39)

Test for food allergies/intolerances to eliminate food-based inflammation. Consider allergy elimination and an anti-inflammatory diet as a template for food-based treatment of inflammation.(40), (41)

I have observed that digestive infections/dysbiosis are common sources of inflammation in breast cancer patients, especially those who have deficiencies in the Earth element from a Chinese Medicine perspective. Test stool and/or urine organic acids to evaluate and guide treatment of dysbiosis. (42) Restore the integrity of the digestive mucosa.

In addition to treating the cause of the inflammation, consider natural anti-inflammatory agents that also inhibit breast cancer such as fish oil, curcumin, and so on. (43-45)

Stress Response

Cancer is not caused by stress alone. (46) The stress response constitutional factor refers to the theory that while the cause of breast cancer is often multifactorial, it may partially result from or progress due to a patient's neurochemical response to chronic stress. There is value in treatments that limit the impact that chronic negative stress response may have on the immune and endocrine systems.

Certain genotypes of the COMT SNP are correlated with breast cancer risk and prognosis. (47), (48) COMT SNPs result in 3- to 4-fold less COMT enzyme activity and therefore inhibition of catecholamine degradation. (49) Prolonged activation of either the sympathetic nervous system or the hypothalamic-pituitary-adrenal axis (stimulator of Cortisol production) may promote tumor growth. (50) One researcher of ovarian cancer stated that the evidence may be even stronger for stress's playing a role in cancer progression. (51) Others found elevations of catecholamines in tumor samples of patients under extreme stress compared with those who were less stressed. (52) In addition, cancer patients reporting higher stress levels have elevated levels of tumor angiogenic cytokines. (53)

[ILLUSTRATION OMITTED]

Consider testing stress response as a constitutional factor by testing the COMT SNP, neurotransmitters, DHEA, diurnal Cortisol, and amino acids as they relate to neurotransmitters (Table 1).

I use a combination of lifestyle, mind-body-spirit treatment, energetic-balancing with acupuncture, and qi gong, as well as Western and Chinese botanicals, amino acids, and other nutritional supplements (Table 1). My goal is to support patients in experiencing longer periods of being in the moment. I have a theory: the more time spent being in the moment, the more time spent vibrating at the appropriate frequency for our cellular being. I like to think that this equates with slowing down those rapidly dividing cancer cells.

Conclusion

Individualized, constitutional treatment of people who have had breast cancer requires adherence to the foundational principles of naturopathic medicine. By identifying and treating the cause, treating the whole person, and inspiring the healing power within each patient by removing obstacles to her cure, we facilitate transformational healing. By combining this approach with evidence-based basic naturopathic care and complementary care methods, we are at the very least inspiring health.

Notes

(1.) Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2008 [Web page]. National Cancer Institute, http://seer.cancer.gov/csr/19752008. Based on November 2010 SEER data submission, posted to the SEER website 2011.

(2.) Ibid.

(3.) Lyman GH, Kuuderer NM, Lyman SL, et al. Menopausal status and the impact of early recurrence on breast cancer survival [online articfej. Moffit Cancer Center & Research Institute, http://www.moffitt.org/moffittapps/ccj/v4n4/article5.html. Accessed December 4, 2011.

(4.) Gloeckler, LA, Eisner MP. Cancer of the female breast. SEER Survival Monograph. 1998-2001;13:101-110. Available at: http://seer.cancer.gov/publications/survival/survbreast.pdf. Accessed December 4, 2011.

(5.) Dunnwald, LK, Rossing MA, Li CI. Hormone receptor status, tumor characteristics, and prognosis: a prospective cohort of breast cancer patients. Breast Cancer Res. 2007;9(1).

(6.) Attiqa N, M'uza MD, Nadeem Q, et al. Prognostic factors in node-negative breast cancer. Ann Surg. 2002;235(1):10-26.

(7.) Brewster AM, et al. Residual Risk of breast cancer recurrence 5 years after adjuvant therapy. J Natt Cancer Inst. 2008;100;DOI:10.1093/jnci/djn233.

(8.) MacDonald B, Jennings K. The Breast Cancer Companion: A Complementary Care Manual. Portland, OR: Brains and Braun Publications; 2010:95-192.

(9.) Ibid.; 200-201,207-208.

(10) Tamoxifen [Web page]. MedlinePlus. http://www.nim.nih.gov/medlineplus/druginfo/meds/a682414.html. Accessed November 27, 2011.

(11.) MacDonald BM, Jennings K. Breast Cancer Companion. 292-305.

(12.) Alschuler L, Gazella Karolyn. The Definitive Guide to Cancer. 3rd ed. Berkeley, CA: Celestial Arts; 2010.

(13.) American Cancer Society. Breast cancer and early detection [online document], http://www.cancer.org/acs/groups/cid/documents/webcontent/003165-pdf.pdf. Accessed December 4, 2011.

(14.) Ibid.

(15.) Marchese M. Environmental exposure history questionnaire-Permission granted by author. Available at: www.drmarchese.com/images/Exposure_Questionnaire.doc. Accessed December 6, 2011.

(16.) Marchese M. Environmental links to breast cancer and endometriosis. Naturopath Doctor News Rev. 2011;7(2):9-10.

(17.) Bugano DD, Conforti-Froes N, Yamaguchi NH, et al. Genetic polymorphisms, the metabolism of estrogens and breast cancer: a review. Eur) Gynaecol Oncol. 2008;29(4):313-20.

(18.) Consider the Genova Diagnostics Laboratory DetoxiGenomic Profile. Available at: http://www.gdx.net/product/10038. Accessed December 6, 2011.

(19.) Muti P, Bradlow HL, Micheli A, et al. Metabolism and risk of breast cancer: a prospective analysis of 2:16 hydroxyestrone ratio and risk of breast cancer in premenopausal and postmenopausal women. Cancer Epidemiol. 2000;11:635-640.

(20.) Eliassen AH, Missmer SA, Tworoger SS, et al. Circulating 2-hydroxy and 16-alph hydroxy! estrone levels and risk of breast cancer among postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2008;17(8):2029-2035.

(21.) Muti P, Bradlow HL, Micheli A, et al. Metabolism and risk of breast cancer: a prospective analysis of 2:16 hydroxyestrone ratio and risk of breast cancer in premenopausal and postmenopausal women. Cancer Epidemiol. 2000;11:635-640.

(22.) Adlercreutz H, Fotsis T, Hockerstedt K, et al. Diet and urinary estrogen profile in premenopausal omnivorous and vegetarian women and in premenopausal women with breast cancer. J Steroid 6ioctiem;l989;34(1-6h527-530.

(23.) McCann SE, Wactawski-Wende J, Kufel K, et al. Changes in 2-hydroxyestrone and 16alpha-hydroxyestrone metabolism with flaxseed consumption: modification by COMT and CYP1B1 genotype. Cancer Epidemiol Biomarkers Prev. 2007;16(2):256-262.

(24.) Nettleton JA, Greany KA, Thomas W, et al. The effect of soy consumption on the urinary 2:16-hydroxyestrone ratio in postmenopausal women depends on equol production status but is not influenced by probiotic consumption. Nutr Cancer. 2005;135(3):603-608.

(25.) Fowke JH, Longcope C, and Hebert JR: Brassica vegetable consumption shifts estrogen metabolism in healthy postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2000;9:773-779.

(26) Bradlow HL and Sepkovic D. Diet and Breast Cancer. Ann NYAcadSci. 2002;963, 247-267.

(27.) Dalessandri KM, Firestone CL, Ritch MD, et a!. Pilot study: effect of 3, 3Q-diindolyImethane supplements on urinary hormone metabolites in postmenopausal women with a history of early-stage breast cancer. Nulr Cancer. 50(2): 161-167.

(28.) Consider Metametrix Clinical Laboratory's Toxic Effects Profiles. Available at: http://www.metametrix.com/test-menu/profiles/categorized. Accessed on December 6, 2011.

(29.) Cole S. Chronic inflammation and breast cancer recurrence. J Clin Oncol. 2009;27(21):3418-3419.

(30.) Ibid

(31.) DeNardo DG, Coussens LM. Inflammation and breast cancer: balancing immune response: crosstalk between adaptive and innate immune cells during breast cancer progression. Breast Cancer Res. 2007;9:2t2.

(32.) Pierce GL, Ballard-Barbash R, Bernstein L, et al. Elevated biomarkers of inflammation are associated with reduced survival among breast cancer patients. J Clin Oncol. 2009;27(21):3437-3444.

(33.) Han Y, Mao F, Wu Y et al. Prognostic role of C-reactive protein in breast cancer: a systematic review and meta-analysis. Int I Biol Markers. Epub 2011 Dec2:0:105301/JBM.2011.8872.

(34.) Cole, op. cit,

(35.) Bachelot T, Ray-Coquard I, Menetrier-Caux C, et al. Prognostic value oi serum levels of interleukin 6 and of serum and plasma levels of vascular endothelial growth factor in hormone-refractory metastatic breast cancer patients. Br J Cancer;2003;88:1721-1726.

(36.) Ibid.

(37.) DeNardo DG, Coussens LM. Inflammation and breast cancer, balancing immune response: crosstalk between adaptive and innate immune cells during breast cancer progression. Breast Cancer Res. 2007;9:212.

(38.) Dirix LY, Salgado R, Weytjens R, et al. Plasma fibrin D-dimer levels correlate with tumour volume, progression rate and survival in patients with metastatic breast cancer. Br I Cancer. 2002;86(3):389-95.

(39.) Giani C, Fierabracci P, Bonacci R et al. Relationship between breast cancer and thyroid disease: relevance of autoimmune thyroid disorders in breast malignancy. J Clin Endocrinol Metabl. 1996;81(3):990-4.

(40.) See Black J. The Anti-Inflammatory Diet and Recipe Book. Alameda, CA; 2006.

(41.) Consider anti-inflammatory resources such as those at drweil.com. Anti-inflammatory food pyramid chart available at http://www.drweil.eom/drw/u/ART02995/Dr-Weil-Anti-lnflammatory-Food-Pyramid.html. Accessed December 6, 2011.

(42.) Elena M. Health, probiotics, and inflammation. J Clin Gastroenterol. 2006;42:S177-S178.

(43.) Mandal CC, Ghosh-Choudhury T, Yoneda T, et al. Fish oil prevents breast cancer cell metastasis to bone. Biochem Biophys Res Commun. 2010;402(4):602-607.

(44.) Simopoulos A. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002 Dec;21 (6):495-505.

(45.) Altenburg JD, Bieberich AA, et al. A Synergistic antiproliferation effect of curcumin and docosahexaenoic acid in SK-BR-3 breast cancer cells: unique signaling not explained by the effects of either compound alone. BMC Cancer. 2011 Apr 21;11:149.

(46.) Nielsen NR, Gronbaek M. Stress and breast cancer: a systematic update on the current knowledge. Nat Clin Pract Oncol. 2006;3(11):612-620.

(47.) Onay UV, Aaltonen K, Briollais L, et al. Combined effect of CCND1 and COMT polymorphisms and increased breast cancer risk. BMC Cancer. 2008;8:6.

(48.) LonglR, Cai Q, Shu XO, et al. Genetic polymorphisms in estrogen-metabolizing genes and breast cancer survival. Pharmacogenet Genomics. 2007;(5):331-338.

(49.) Dauvilliers Y, Neidhart E, Lecendreux M, et al. MAO-A and COMT polymorphisms and gene effects in narcolepsy. Mol Psychiatry. 2001;64):369.

(50.) Ross, K. Mapping pathways from stress to cancer progression. J Natl Cancer Inst. 2008;100(13):914-917.

(51.) Ibid.

(52.) Lee JW, Shahzad MMK, Lin YG, et al. Surgical stress promotes tumor growth in ovarian carcinoma. Clin Cancer Res. 2009;15(8):2695-2701.

(53.) Lutgendorf SK, Lamkin DM, Jennings 1MB, et al. Biobehavioral influences on matrix metalloproteinase expression in ovarian carcinoma. Clin Cancer Res. 2008;14(21):6839-6846. (41.) Consider anti-inflammatory resources such as those at drweil.com. Anti-inflammatory food pyramid chart available at http://www.drweil.eom/drw/u/ART02995/Dr-Weil-Anti-lnflammatory-Food-Pyramid.html. Accessed December 6, 2011.

by Barbara MacDonald, ND, LAc, MSOM

Barbara MacDonald, ND, LAc, MSOM, coauthored The Breast Cancer Companion: A Complementary Care Manual, a practitioner's guide to support women through conventional cancer treatment (2010). Dr. MacDonald graduated from National College of Naturopathic Medicine (NCNM) with degrees in naturopathic medicine and Classical Chinese medicine (1997, 2003 respectively). She did women's health with a focus on breast cancer care at A Woman's Time in Portland, Oregon, for 14 years. After her residency, she was adjunct teaching faculty at NCNM, where she started the first dual-degree cancer teaching shift. She returned to New England in 2010. She currently practices at Camden Whole Health in midcoast Maine, where she continues to write and lecture on the subject of breast cancer care. Contact: www.thebreastcancercompanion.com or drbarbmacdonald@yahoo.com.
Table 2: Substances Contraindicated and Synergistic with
Hormone-Modifying Medication

Tamoxifen (TAM) selective estrogen-receptor modulator

Avoid        Powerful inhibitors of CYP2D6 pathway such as SSRIs,
             moderate inhibitors such as OTC antihistamines,
             berberines, less concern with mild inhibitors like
             Panax ginseng. (1-5)

             Agents metabolized by the CYP3A4 pathway such as
             St. John's wort, especially in the elderly; moderate
             inhibitors (rhodiola, gaultheria, uva ursi),
             echinacea, and other mild 3A4 inhibitors appear
             to be safer. (6-9)

Synergistic  mdole-3-carbinole enhances TAM effect; may
             also increase toxic metabolites (caution:
             hepatotoxicity). (10) DIM has
             no effect on TAM metabolism. (11)

             Green tea, omega-6 (gamma linolenic acid),
             and melatonin may enhance effect of TAM in
             vitro. (12-15)

             Diet high in vegetables associated with reduced
             risk of recurrence among TAM users. (16)

             Flax seeds enhanced the tumor-inhibiting effect of
             TAM-resistant breast cancer cells in mice. (17)

             Quercetin enhances the effect of TAM in vitro
             and may reduce acquired TAM resistance. (18), (19)

             Black cohosh reduces hot flashes among TAM
             users, enhances the inhibition of proliferation
             of TAM in vitro; possible concern for 2D6 and 3A4
             inhibition, caution; may increase hepatotoxicity of TAM.
             NB: Black cohosh may increase the risk of lung
             metastasis in those with HER2+breast cancer. (20-23)

             Vitamin E enhances the tumor inhibition of
             TAM in vitro and tocotrienols were found to
             increase survivorship by as much as 60%
             among TAM users; the result was not
             statistically significant. (24), (25)

             Dietary intake of soy isoflavones combined with
             TAM (in postmenopausal American women)
             resulted in 60% reduction in breast cancer
             recurrence comparing highest with lowest
             intake; "appears not to interfere with tamoxifen
             efficacy." (26)

             Silymarin, grapeseed extract, and curcumin
             reduced hepatotoxicity in TAM-intoxicated
             rats. (27) Taurine appears to do the same. (28)

Notes        Consider CYP2D6 and CYP 3A4
             polymorphism testing to ensure
             proper drug metabolism. See notes below.

Aromatase Inhibitors (Al)

Avoid        Inducers of the CYP3A4 drug metabolism
             pathway may lower plasma concentrations of
             Als (see notes) such as St. John's
             wort (especially in the elderly)
             and berberine-rich plants
             like goldenseal, which may interfere
             with efficacy of these
             medications. (29), (30)

             Caution is recommended when taking
             with other 3A4 substrates and inhibitors
             (such as
             SSRIs, antifungals, antibiotics, opiates,
             ginkgo, milk thistle, grapefruit juice, gaultheria,
             rhodiola, uva ursi) as plasma concentrations of Als may
             increase resulting in. toxicity
             For a list of substrates and inhibitors, consider;
             http:ctep.cancer.gov/protocolDevelopment/docs/cyp3a4.doc
             (31), (32)

             A study to evaluate the safety of flaxseed
             consumption by those taking anastrozole is
             under way. (33)

Synergistic  Women eating the most soy with anastrozole
             had 33% lower recurrence vs. those who
             ate the least. (34)

             Curcumin enhances the effect of letrozole
             in mice endometrial cancer model. (35)

             Vitamin D: Achieving a 40 ng/mL
             concentration of 250HD may prevent Al-induced
             arthralgia. Routine pre-AI vitamin D
             testing recommended due to risk of bone loss
             with Als. (36), (37)

Notes        Consider CYP3A4 polymorphism testing to identify
             errors in drug metabolism and inform selection.

SERM; selective estrogen receptor modulator such as tamoxifen
(TAM) commonly used in premenopausal survivors
Al: aromatase inhibitor such as anastrozole (Arimidex),
exemestane (Aromasin), and letrozole (Femara) used only in
postmenopausal survivors to block the conversion of adrenal
testosterone to estrogen SSRI: selective serotonin reuptake
inhibitor
Notes: Tamoxifen-treated patients carrying CYP2D6 variants that
impaired formation of 4-hydroxytamoxifen, had more than double
the risk of recurrence of breast cancer, shorter reiapse-free
periods, and worse event-free survival rates compared with patients
with functional CYP2D6. (38) Those with CYP3A41b variants are at
higher risk of endometrial cancer. (39) Femara only mildly inhibits
3A4; Arimidex moderately inhibits 3A4; Aromasin is metabolized by
3A4 and has the greatest risk of interactions with other
3A4-metabolised drugs. (40)

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estrogen and tamoxifen in response to treatment
of rats with 3.3'-diindolylmethane and its parent
compound indole-3-carbinol. Cancer Detect Prev.
2004; 28(1):72-79.
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(18:3n-6) is a selective estrogen-response modulator
in human breast cancer cells: gamma-linolenic acid
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represses estrogen receptor expression and
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(Faslodex) efficacy in human breast cancer cell.
Int J Cancer. 2004;109(6):94[pounds sterling]-954.
(15.) Kubatka P, Bojkova B, Cikova-Kalicka K. et
a!. Effects of tamoxifen and melatonin on mammary
gland cancer induced by N-methyl-n-nitrosourea
and by 7(12-demethylbenz(a)anthracene, respectively,
in female Sprague-Dawiey rats. Folia fiio.
2001;47(1):5-l0.
(16.) Thomson CA, Rock CL, Thompson PA, et al.
Vegetable intake is associated with reduced breast
cancer recurrence in tamoxifen users; a secondary
analysis from the Women's Healthy Eating and
Living Study. Breast Cancer Res Treat.
2011;125(2):519-527.
(17.) Thompson L, Chen J, Hui E, et al. Interactive
effects of flaxseed and tamoxifen on human breast
cancer. Clinical Cancer Research. 2004;10:7703-7711.
(18.) Shin SC. Choi JS. Li X. Enhanced bioavailability
of tamoxifen after oral administration of tamoxifen
with quercetin in rats. Int J Pharm.
2006;26(1-2);144-149.
(19.) Oh SJ, Kim O, Lee JS, eta!. Inhibition of
angiogenesis by quercetin in tarnoxilen-reststant
breast cancer ceils. Food Chem lox'tcoi.
2010;48(11):3227-3234.
(20.) Kanadys WM. Leszczynska-Gorzeleak B.
Oleszczuk J. Efficacy and safety of Black Cohosh
(Actaea/Cimicifuga racemosa) in the treatment of
vasomotor symptoms-review of clinical trials.
Ginekol Pol. 2008;79(4):287-296.
(21.) Bodinet C, Freudenstein J. Influence of
Cimicifuga racemosa on the proliferation of
estrogen receptor-positive human breast cancer
celts. Breast Cancer Res Treat 2002;76(1);1-10.
(22.) Li J. Godecke T, Chen SN. et al. In vitro
metabolic interactions between black cohosh
(Cimicifuga racemosa) and tamoxifen via inhibition
of cytochrome P450 2D6 and 3A4. Xenobiotha. Epub
2011 Aug 9. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/21827327.
Accessed Nov. 27. 2011.
(23.) Davis, V. Jayo M, Ho, A. et al. Black
cohosh increases metastatic mammary cancer in
transgenic mice expressing c-erbB2- Cane Res.
2008;68;8337.
(24.) Guthrie N, Gapor A. Chambers A, Carroll
KK: Inhibition of proliferation of estrogen
receptor negative MDA-MB-435 and positive MCF-7
human breast cancer cefts by patm tocotrienols
and tamoxifen, alone or in combination. J Nutr.
1997;127:544S-548S.
(25.) Nesaretnam K, Meganathan P, Veerasenan SD.
et al. Tocotrienols and breast cancer: the
evidence to date. Genes Nutr. Epub 2011 Apr
24. Available at http://breast-cancer-research.com
/content/pdf/bcr2726.pdf. Accessed Nov 27,2011.
(26.) Guha N, Kwan ML, Quesenberry CP Jr. et al.
Soy isoflavones and risk of cancer recurrence in
a cohort of breast cancer survivors: the Life
After Cancer Epidemiology study Breast Cancer
Res Treat. 2009;118(2):395-405.
(27.) El-Beshbishhy HA, Mohamadin AM, Nagy AA,
et al. Amelioration of tamoxifen-induced liver
injury in rats by grape seed extract, black seed
extract and curcumin. Indian J Exp Bioi
2010;48(3):280-288.
(28.) Tabassum H, Rehman H, Banerjee BD, et
al. Attenuation of tamoxifen-induced hepatotoxicity
by taurine in mice. Clin ChimActa 2006:370(1-2):
129-36.
(29.) List of drugs that may have potential
CYP3A4 interactions. Available at: ctep.cancer.
gov/protocolDevelopment/docs/cyp3a4.doc. Accessed
November 27, 2011. Adapted from Cytochrome P450
enzymes: substrates, innibftors, and inducers,
in: lacy CF, Armstrong It, Goldman MP, Lance LL,
eds. Dnig Information Handbook. 15th ed. Hudson,
OH; LexiComp Inc.; 2007:1899-1912.
(30.) Gurley B, Swain A. Hubbard M et al.
Clinical assessment of CYP206-mediated herb-drug
interactions in humans: Effects of milk thistle,
black cohosh, goldenseal, kava kava, St. John's
wort and Echinacea. Mo/Nutr Food Res. 2008 Jury;
52(7);755-763.
(31.) Scott IM, Leduc Rl, Burt AJ. et al. The
inhibition of Human Cytochrome P450 by Ethanol
Extracts of North American Botanicals. Pharmac
Biology. 2006;44(5):315-327.
(32.) List of drugs that may have potential
CYP3A4 interactions. Op cit.
(33.) Flaxseed, aromatase inhibitors and breast
tumor characteristics (FABrC) [Web page].
http://clinicaltrials.gov/ct2/show/NCT00612560.
Refer to ClinicaiTrials.gov identifier:
NCT00612560. Accessed Nov. 27, 2011.
(34.) Kang X, Zhang Q, Wang S. et al. Effect
of soy isoflavones on breast cancer recurrence
and death for patients receiving adjuvant
endocrine therapy. CMAJ. 2010;182(17):1857-1862.
(35.) Liang YJ, Zhang HM. Wu YZ, et al.
Inhibiting effect of letrozole combined with
cuTCumin on xenogiafted endometrial carcinoma
growth in nude mice. Chin J Cancer. 2010;29(1)
:9-14,
(36.) Prieto-Alhambra 0, Javaid MK. Servitja S.
et al. Vitamin D threshold to prevent aromatase
inhibitor-induced arthralgia: a prospective
cohort study. Breasr Cancer Res Treat. 2011;
125(3):869-878.
(37.) Nogues X, Servitja S, Pena MJ, et al.
Vitamin D deficiency and bone mineral density
in postmenopausal women receiving aromatase
inhibitors for early breast cancer. Mafuntes.
2010;66(3):291-297.
(38.) Schroth W. Antoniadou L, Fritz P, et al.
Breast cancer treatment outcome with adjuvant
tamoxifen relative to patient CYP2D6 and
CYP2C19 genotypes. J Clin Oncol. 2007;25(33):
5187-5193.
(39.) Chu W, Fyles A, Sellers E, et al. Association
between CYP3A4 genotype and risk of endometrial
cancer following tamoxifen use. Carcinogenesis.
2007,28 (10): 2139-2142.
(40.) Buzdar A. Pharmacology and pharmacokinetics
of the newer generation aromatase inhibitors.
Clinic Cancer Res. 2003;9:468s.
Table 3: Lifestyle Modifications that Lower the Risk of
Recurrence of Breast Cancer

Fitness/Shape

Exercise           There was a 50% greater chance of   WHEL trial:
                   being a survivor in those who got   1490 women
                   the equivalent of 30 minutes of     diagnosed and
                   exercise 6 days a week or 3 hours   treated for
                   weekly. (1)                         earty-stage
                                                       breast cancer
                                                       between 1991
                                                       and 2000.

                   Not only does physical activity     Prospective
                   increase survivorship, but the      observational
                   amount matters. The women who       study based on
                   exercised 3-5 hours a week at an    responses from
                   average pace (2-2.9 mph) were 50%   2987
                   more likely to be long-term         participants in
                   survivors. The women who only       the Nurses'
                   exercised 1-3 hours a week were     Health Study
                   30% less likely to survive. (2)     who were
                                                       diagnosed with
                                                       stage I, II. or
                                                       Ml breast
                                                       cancer between
                                                       1984 and 1998.

                   Women who increased their activity  Prospective
                   level after diagnosis and           observational
                   treatment had a 45% higher chance   study of 933
                   of survival and\hose who reduced    women; (Hearth.
                   their posttreatment activity had a  Eating.
                   four-fold lower chance of           Activity, and
                   survival. Modest increase in        Lifestyle
                   posttreatment fitness improves      Study)
                   prognosis. (3)                      diagnosed with
                                                       local or
                                                       regional breast
                                                       cancer
                                                       (1995-1998);
                                                       observed until
                                                       death or 2004.

Body mass index    Those who had a body mass index of  1453 women with
                   less than 25 or a waist-to-hip      invasive breast
                   ratio (WHR) of less than or equal   cancer,
                   to 0.85 were 38% more likely to be  diagnosed
                   a survivor than those whose BMI     1991-1994 were
                   was greater than or equal to 30 or  interviewed
                   a WHR of O.80. (Low vegetable and   during
                   fruit consumption and current or    follow-up;
                   past smoking were also associated   Italian
                   with worse breast cancer            multicenter
                   survival.) (4)                      case-control
                                                       study.

Body fat           Women with higher percentage of     2010 review of
                   body fat had a 30% lower risk of    epidemiologic
                   surviving breast cancer. The most   studies
                   consistent finding was that         conducted at
                   adiposity was associated with a     Moores UCSD
                   30% increased risk of mortality.    Cancer Center.
                   (5)

Beveraqes/Diet

Alcohol            Drinking 3 to 4+ drinks per week    Kaiser's Life
                   is associated with a 1,3-foid       After Cancer
                   increased risk of breast cancer     Epidemiology
                   recurrence. (5)                     (LACE)
                                                       prospective
                                                       study of 189?
                                                       early stage
                                                       breast cancer
                                                       survivors
                                                       diagnosed
                                                       between 1997
                                                       and 2000

Green tea          One meta-analysis reported that     2010
                   more than 3 cups of green tea       meta-analysis
                   consumed daily reduces the risk of  of other
                   recurrence by 27% while 5+ cups     studies, 5617
                   was required in the 2005 analysis.  cases and 2005
                   (7), (8)                            systematic
                                                       review and
                                                       meta-analysis.

Vegetables/fruits  There was a 50% greater likelihood  This
& fitness          of being a survivor among those     prospective
                   who consumed five or more servings  study was
                   of vegetables and fruits daily and  performed of
                   who accumulated 540+ metabolic      1490 women
                   equivalent tasks-min/ wk            diagnosed and
                   (equivalent to walking 30 minutes   treated for
                   6 d/wk); only the combination was   early-stage
                   associated with a significant       breast cancer
                   survival advantage. (9)             between 1991
                                                       and 2000.

                   Note: the Women's Healthy Eating
                   and Living trial did not find high
                   vegetable and fruit consumption to
                   more benefit compared with
                   controls in the general first
                   analysis of the study However, a
                   subgroup of women taking tamoxifen
                   who ate the most servings of
                   cruciferous vegetables daily had a
                   52% lower recurrence rate than
                   those who ate the fewest servings.
                   (10)

Soy isoflavones    Asian women who ate the most soy    5042 Chinese
                   foods had the least recurrence and  breast cancer
                   the greatest survival. (11)         survivors ages
                   Another study found that among      20-75 diagnosed
                   postmenopausal American women who   between
                   take tamoxifen, those who ate the   2002-2006 vs.
                   equivalent of isoflavones in an     California
                   Asian diet had a 60% reduction in   cohort of 1954
                   breast cancer recurrence. (12)      survivors from
                   Note: published warnings regarding  1997-2000 in a
                   the differences in the epigenetics  prospective
                   of American breast cancer           assessment of
                   survivors (vs. Asian) caution the   isoflavone
                   consumption of soy foods equaling   consumption.
                   the equivalent of the Asian diet
                   until more data are available.
                   (13)

Dietary intervention trials in review and support of limiting
animal fat for breast cancer survivorship
The Nurses' Health Study reported no evidence suggesting that
lower intake of total fat or a specific type of fat was associated
with death from breast cancer. 14
Higher levels of dietary intake of butter, margarine, lard, and
beef were found to increase the risk of recurrence. There was also
an increased risk associated with consumption of red meat, liver,
and bacon, corresponding to a doubling of the risk for each time
per day that foods in this category were consumed (p = 0.09). 15
During the Women's Intervention Nutrition Study (WINS), women
counseled to reduce fat intake to 15% of calories had a 24% lower
risk of recurrence compared with the control group counseled to
eat between 20-35% calories from fat (p < 0.05). 16
Basic recommendations for therapeutic lifestyle modifications
to reduce risk of recurrence of breast cancer:
* Exercise 3-5 hours a week, at least more than you did before
you were diagnosed.
* Optimize BMI, waist/hip ratio, and body fat to meet study
guidelines listed above.
* Drink fewer than three alcoholic beverages weekly.
* Drink 5-10 cups of green tea a day (or the equivalent in
capsules).
* Eat a diet high in fiber with a therapeutic dose (5-10
half-cup portions) of a variety of local, organic vegetables
(particularly cruciferous) and fruits (particularly berries)
daily, and limit or eliminate animal protein and, if eaten,
use free-ranging, hormone-free sources.
* Eat organic, whole soy foods if you are from Asia, were raised
on an Asian equivalent of soy, and/or are on tamoxifen.

(1.) Pierce JP. Stefanick ML. Flatt SW. et al. Greater
survival after breast cancer in physically active women with
high vegetable-fruit intake regardless of obesity. J Clin
Oncol 2007;25(17):2345-2351.
(2.) Holmes M. Chen W. Feskanich D. et al. Physical
activity and survival after breast cancer diagnosis.
JAMA. 2005;293:2479-2486.
(3.) Irwin M, Smith A, McTiernan A, et al. Influence of
pre-and postdiagnosis physical activity on mortality in
breast cancer survivors; The health, eating activity,
and lifestyle study. J of Cfift One. 2008;26(24).3958-3964.
(4.) Dal Maso L, Zucchetto A, Talamini R. et at.
Effect of obesity and other lifestyle factors on mortality
in women with breast cancer. Int J Cancer. 2008;123(9):2188-2194.
(5.) Patterson RE, Cadmus LA, Emond JA, et al. Physical
activity, diet, adiposity and female breast cancer
prognosis: a review of the epidemiologic literature.
Maturitas. 2G10;66(1):5-15.
(6.) Kwan ML. Kushi LH. Weltzien E, et al. Alcohol
consumption and breast cancer recurrence and survival
among women with early-stage breast cancer: the life
after cancer epidemiology study. J Clin Oncol.
2010;28(29):4410-4416.
(7.) Ogunleye AA, Xue F, Michels KB. Green tea
consumption and breast cancer risk or recurrence:
a meta-analysis. Breast Cancer Res Treat.
2010;119(2):477-484.
(8.) Seely D, Mills EJ. Wu P, et at. The effects
of green tea consumption on incidence of breast
cancer and recurrence of breast cancer; a
systematic review and meta-analysis. Integr
Cancer Trier. 2005;4(2):144-155.
(9.) Pierce JP, Stefanick ML, Flatt SW, et al.
Greater survival after breast cancer in physically
active women with high vegetable-fruit intake
regardless of obesity. J Clin Oncol.
2007;25(17):2345-2351.
(10.) Thomson CA, Rock CL, Thompson PA, et al.
Vegetable intake is associated with reduced
breast cancer recurrence in tamoxifen users:
a secondary analysis from the Women's Healthy
Eating and Living Study. Breast Cancer Res
Treat. 2011 125(2):519-527.
(11.) Ou Shu X, Zheng Y, Cai H. et al. Soy food
intake and breast cancer survival. JAMA.
2009;302(22):2437-2433.
(12.) Guha N, Kwan ML. Ouesenberry CP Jr. et
al. Soy isoflavones and risk of cancer recurrence
in a cohort of breast cancer survivors: the Life
After Cancer Epidemiology study. Breast Cane Res
Treat. 2009;118(2):395-405.
(13.) Hilakivi-Clarke L, Andrade JE, Helferich W.
Is soy consumption good or bad for the breast? J
Nutr 2010;140(12):2326S-2334S.
(14.) Holmes MD. Hunter DJt Colditz GA. et al.
Association of dietary intake of fat and fatty
acids with risk of breast cancer JAMA.
1999:281:914-920.
(15.) Hetert JR. Huriey TG. Ma Y (19%) The
effect of dietary exposures on recurrence and
mortality in early stage breast cancer. Breasf
Cancer Res Treat. 51:17-28.
(16.) Chlebowski, R.. G. Blackburn, et at.
Dietary fat reduction and breast cancer outcome:
interim efficacy results from the Women's
Intervention Diet Study. J Natl Cancer Inst.
2006;98:1767-1776.
Table 4: Natural Therapeutic Interventions and Prevention of
Recurrence of Breast Cancer

Vitamin supplements taken the      Breast cancer survivors with serum
first six months after treatment   vitamin D concentrations at 55
resulted in lower recurrence and   nmol/L had a 1.55 times longer
18% reduced risk of mortality.     disease-free survival than those
The authors stated: "Our results   with 35 nm/L concentration.2
do not support the current         However, this was not seen in the
recommendation that breast cancer  WHEL trial where no relation
patients should avoid use of       between vitamin D and breast cancer
vitamin supplements." (1)          recurrence was found. (3)

There is a (nonsignificant) lower  Increased green tea consumption
risk of recurrence and             (more than three cups a day) was
disease-related mortality among    inversely associated with breast
those who self-reported using      cancer recurrence (pooled RR =
vitamins C and E for three years   0.73, 95% CI: 0.56-0.96) in a
posttreatment (vitamin E nearly    meta-analysis of 5716 cases. (5)
halved the risk.) (4)

Black cohosh lengthened            A pilot study evaluated the
disease-free survival among        survival of patients with various
18,861 patients observed for 3.6   types of end-stage cancer including
years. After 2 years following     breast. 76% of those who received
initial diagnosis, 14% of the      supplements of coenzyme Q10 and a
control group had developed a      mixture of other antioxidants
recurrence, while the black        (e.g., vitamin C, selenium, folic
cohosh extract group didn't reach  acid and beta-carotene) survived
this proportion until after 6.5    longer than predicted among the
years.6 However, black cohosh was  treatment group; on average,
found to increase the risk of      surviving 5 more months than the
lung metastasis in                 control group. (8)
HER2-expressing transgenic mice.
Caution in HER2+ patients is
advised. (7)

The disease-free survival was      Daily administration of melatonin
increased from 84% to 100% when    significantly increased the
PSK (extract from Coriolus         survival time of tumor-bearing
versicolor) was added to biannual  animals. This is only recommended
chemotherapy x 5 years. They       for those with ER+ tumor history.
studied 134 randomly selected      (10)
breast cancer survivors who were
HLAB40+. The benefit was not
apparent among those whose tumors
were HLAB40-. (9)

From these studies, I might recommend that a posttreatment
patient with ER+ breast cancer consider:
* whole-foods multivitamin/mineral complex without iron (such as
Innate's Iron-free one daily)
* selenium, 400 meg from food (100 mg per Brazil nut) and
supplementation combined
* vitamin D3 to achieve serum concentration of 50-60 ng/mL
* green tea at 5+ cups a day or the equivalent in capsules
(two 300 mg capsules of Vitanica's green tea, which include
50 mg of whole plant (95% polyphenols,80% catechins, 55% EGCg,
10% caffeine)
* Coriolus versicolor mushroom extracts from JHS Natural Products
(five 600 mg capsules daily in divided doses) n 6 months minimum
and either add or put in quarterly rotation with therapeutic
dosages ofcurcumin, artemisia, astragalus, AHCC, or arabinogalactan,
etc.
* melatonin, 20 mg at bed

(1.) Nechuta S, Lew W, Chen 2, et al. Vitamin supplement use
during breast cancer treatment and survival: a prospective
cohort study. CancerEpidem Biomark Prev. 2011;20(2):262-271.
(2.) Goodwin PJ, Ennis M. Pritchard, et al. Prognostic
effects of 25-hydroxyvitamin D levels in early breast
cancer J Clin Oncol. 2O09;27(23):3757-3763.
(3.) Jacobs ET, Thomson CA( Flatt SW. et al. Vitamin D
and breast cancer recurrence in the Women's Healthy Eating
and Living (WHEL) Study. Am J Clin Nutr. 2001;93(1):108-117.
(4.) Fleischauer AT, Simonsen N, Arab L. Antioxidant
supplements and risk of breast cancer recurrence and
breast cancer-related mortality among postmenopausal
women. Nutr Cane. 2003:46(1): 15-22.
(5.) Ogunleye AA, Xue F. Micheis KB. Green tea consumption
and breast cancer risk of recurrence: a meta-analysis.
Breast Cancer Res Treat 2010;119(2):477-484.
(6.) Henneicke-von Zepelin HH, Meden H, Kostev K,
Isopropanolic black cohosh extract and recurrence-free
survival after breast cancer. Int J Clin Pharmacol
Ther. 2007;45:143-154.
(7.) Davis. V, Jayo MJ. Ho A. et al. Black cohosh
increases metastatic mammary cancer in transgenic
mice expressing c-erbB2. Cancer Res. 2008:68:8377.
(8.) Hertz N, lister RE. Improved survival in patients
with end-stage cancer treated with coenzyme Q(10) and
other antioxidants: a pilot study. J Int Med Res.
2009:37(6): 1961-1971.
(9.) Yokoe T. lino Y, Takei H, et al. HLA antigen
as predictive index for the outcome of breast cancer
patients with adjuvant immunochemotherapy with PSK.
Anticancer Res. 1997;17(4A);2815-2818.
(10.) Saez MC. Barriga C. Garcia JJ, et al. Melatonin
increases the survival time of animals with untreated
mammary tumours: neuroendocrine stabilization. Mol
Cell Biochem. 2005;278(1-2):15-20.


Table 1: The Role of Naturopathic Care After Conventional Breast
Cancer Treatment

Complementary Care

Help patients  For those taking hormone-modifying medications, offer
recover from   natural treatments that reduce side effects and
side effects   potential drug toxicity. Educate patients about and
and long-term  avoid contraindications. Offer agents that act
toxicities     synergistically (see Table 2, p.78).
that may
result from
surgery,
chemotherapy,
and/or
radiation and
accompanying
oral
medications.

Basic
Naturopathic
Care

Inspire        Provide evidence-based supplements and
patients with  botanicals that have been found to
research on    reduce the risk of recurrence of
lifestyle      breast cancer (see Table 4, p. 81).
changes found
to
dramatically
reduce the
risk of
recurrence
and help them
implement
these
lifelong
goals (see
Table 3, p
80)

Optimize     Optimize                    Optimize
immune       Reduce        Optimize      function of
antioxidant  function and  exposure to   detoxification
status       reduce        environmental  pathways.
primarily    inflammation  toxins
through
diet.

Improve     Manage
metabolism  response
of          to stress
hormones.   and
            encourage
            mindfulness.

Individualized, Constitutional Treatment

In addition to the above, use naturopathic foundational principles to
evaluate and treat the individual. Consider the following
constitutional categories, take a thorough history, do a physical
examination, test your clinical hypotheses, and methodically
treat each layer until a healthy constitution is restored.

Detoxification        Inflammation                Stress Response
Take a toxic     Question and examine for         Take a social
exposure         symptoms and signs of            history, life
history and      inflammation.                    stressor, and
listen for                                        trauma history and
other symptoms                                    observe for signs
that may relate                                   of tension in face,
to toxicity of                                    muscles. posture,
chemicals,                                        and pulse.
metals,
hormones, etc.
(1)

Test:            Test:                            Test:

* single         * appropriate conventional       * methylation SNPs
nucleotide       markers of inflammation such as  (12), (13)
polymorphisms    CRP7, (8)
(2)

* organic acids  * food allergies                 *
for hepatic                                       Neurotransmitters:
stress (3)                                        (catecholamines,
                                                  GABA, etc.) (14)

* amino acids    * digestive function, digestive  * DHEA, diurnal
related to       infection, flora and dysbiosis   Cortisol rhythm
detoxification   (9)                              (15), (18)
(4)

* specific       * thyroid function and           * serum amino acids
toxin load (5)   autoimmune antibodies (10),      for precursors to
                 (11)                             neurotransmitters
                                                  and GABA (17)

* estrogen
metabolism (6)
Educate/coach:   Educate/coach:                   Educate/coach:

* tools for      * avoid pro-inflammatory foods   * schedule
avoidance of     (20)                             modifications to
xenoestrogens                                     reduce rushing
and other
concerning
toxins
determined by
above testing
(18)

* foods and      * avoid persona! allergens       * cultivate inner
beverages for                                     peace with
detoxification                                    mindfulness, qi
(19)                                              gong, yoga, tai
                                                  chi, etc.
                 * increase anti-inflammatory     * optimize fitness
                 foods (21)                       (22-25)

Treatment:       Treatment:                       Treatment:

* replenish      * treat dysbiosis; restore       * botanicals for
deficient amino  proper balance of bowel flora    calming the mind
acids            (28)                             and Shen (35)

* safely timed   * implement therapeutic          * amino acids based
toxin-specific   anti-inflammatory/anti-allergic  on deficiencies +
cleansing until  diet                             L-theanine (36)
normal on
retesting (26)

* optimize       * naturopathic and Chinese       * adrenal tonics
2:16oh-estrone   Medicine protocols to reduce     based on
(27)             chronic inflammation such as     test
results
                 curcumin, fish oil (29-32)

* quarterly      * Optimize thyroid function      * body-mind-spirit
10-day cleanse   (33), (34)                       therapies
                                                  *
                                                  energetic/meridian
                                                  treatments (37)

(1.) Marchese M. Environmental exposure history
questionnaire. Permission granted by author Available
at: www.drmarchese.com/images/Exposure.Questionnaire.doc.
Accessed December 6, 2011.
(2.) Consider the Genova Diagnostics Laboratory DetoxiGenomic
Profile. Available at: http://www.gdx.net/product/10038.
Accessed
(3.) December 6. 2011
(4.) Consider Metametrix Clinical Laboratory's Urine Organic
Acids Profiles. Available at: http://www.metametrix.com/test
-menu/profiles/organic-acids/organix-comprehensive.
Accessed December 6, 2011.
(5.) Consider Metametrix Clinical Laboratory's Amino
Acid 20 plasma profile. Available at: http://www.metametrix.com
/test-menu/profiles/amino-acids/amino-acids-20-plasma.
Accessed December 6, 2011.
(6.) Consider Metametrix Clinical Laboratory's Toxic
Effects Profiles. Available at: http://www.metametrix.com
/test-menu/profiles/categorized. Accessed on December 6, 2011.
(6.) Consider Genova Diagnostic Laboratory Estrogen
Metabolism Assessment. Available at: http://www.gdx.net/
core/one-page-test-deschptions/Estrogen-Metabolism-Assess-
Test-Descriptton.pdf. Accessed December 6, 2011.
(7.) Pierce GL, Ballard-Barbash R, Bernstein L, et al.
Elevated biomarkers of inflammation are associated with
reduced survival among breast cancer patients. J Clin
Oncol. 2009:27(21):3437-3444.
(8.) Han Y. Mao F. Wu Y, et al. Prognostic roie of
C-reactive protein in breast cancer: a systematic
review and meta-analysis. Int J Biol Markers. Epub2011
Dec 2:0:105301/JBM.2011.8872.
(9.) Elena M. Health, probiotics, and inflammation. J
Clin Gastroent, 2008; 42:S177-S178.
(10.) Giam C, Fierabracci P. Bonacci R. et al.
Relationship between breast cancer and thyroid disease:
relevance of autoimmune thyroid disorders in breast
malignancy. J Clin Endocrinol Metab. l996; 81(3):990-994.
(11.) Giustarini E. Pinchera A. Fierabracci R et al.
Thyroid autoimmunity in patients with malignant and
benign breast diseases before surgery. Eur J Endocrinol.
2006;154(5):645-649.
(12.) Thompson PA, Shields PG, Freudenheim JL, et ai.
Genetic polymorphisms in Catechoio-O-methyltransferase,
menopausal status, and breast cancer, Cancer Res.
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