WEDNESDAY, March 13, 2002

"East Meets West: The Role of Integrative Medicine in the Treatment of Breast Cancer "

The Forum this evening is a departure from our usual format. We are presenting a panel discussion on the role of complementary and alternative medicine in breast cancer.

Our participants include:

Debu Tripathy, M.D., Director of the CAM program, UCSF Breast Care Center,

Bradly Jacobs, M.D., Medical Director, Osher Center for Complementary Medicine,

Beverly Burns, LAc., Clinical Director, Charlotte Maxwell Clinic,

Jnani Chapman, CMT, Massage Therapist,

Jane Kramer, Breast cancer patient who has incorporated CAM in her treatment plan, and

Holly Hough, PhD., manager of the CAM program at UCSF Breast Care Center, who will moderate the panel.

HH: We’ll take a few minutes to let the panel share their expertise and knowledge.

DT: Thank you all for being here. I am a medical oncologist as you know, and I got involved in this area from a research perspective because of the void of information in this area. Our program has been trying to design some trials because complementary medicine is widely used by people with breast cancer, particularly in this part of the country.

BB: I am very happy to have the opportunity to work with women who have cancer and to use Chinese medicine. I am very aware that I am working in a field that does not have evidence-based medicine, so that we cannot say we know with certainty what the effect of the treatment will be. Much of what I do is based on traditional practices and the belief that it is beneficial. It is necessary to pull all treatments together so that they can complement each other and to communicate well with providers.

JC: I have been practicing massage on people with cancer since 1986. Historically, massage has been used in physical therapy for pain relief and muscle relaxation, and for reducing the anxiety of hospitalization. We are beginning to developing a body of research starting with the Stanford studies on infants and touch and research done by Tiffany Fields, but there is not a lot of national research regarding its use in the treatment of cancer. A book I might recommend is called Medicine Hands and really covers massage therapy for people with cancer.

JK: I was diagnosed with breast cancer a little over a year ago. I had a lumpectomy, 6 months of chemotherapy and then a mastectomy. In addition to these treatments I actively sought alternative and complementary care. I had acupuncture and Chinese medicine throughout my chemotherapy and continue to have it, tailoring the CHT to my different stages of chemotherapy. I also had frequent massage which was really helpful. I continued to exercise several times a week even during the chemotherapy when it was very difficult. I also continued with my music as my practice. All of this has been extremely useful for me. I found that chemotherapy was not as difficult for me as I thought it would be and I attribute this to the alternative and complementary regimens I have used.

BJ: I am very fortunate to be at this medical center at this time. It is profoundly different than even 10 years ago relative to the interest of the traditional medical staff. The Osher Center is in the process of bringing together practitioners of all disciplines. At a recent meeting I found that one traditional medical staffer had once been a yoga instructor, another was a breast cancer survivor married to an acupuncturist. This was a very pleasant surprise to me and indicates that things are really changing.

HH: We will now open up to questions from the floor.

BB: This is difficult because insurance companies want to support proven treatment plans. Acupuncture has been shown to be effective for pain, post surgical pain and chemo induced nausea, so you can bill for these very specific treatments.

DT: The only thing that I would add is that some insurance plans do allow some flexibility, choices. Study your plan carefully and take the time to understand the options open to you. Otherwise, come the November open enrollment period vote with your feet. Support the kind of initiatives that offer funding for research.

BJ: Here in the Bay Area, State Senator John Burton is currently putting forth an initiative for mandatory insurance coverage for acupuncture treatment. Another critical piece is to show that these treatments actually save money when used in conjunction with traditional Western medicine.

How can we find out about the research programs we can participate in?

BJ: The Cancer Center has a listing of the clinical trials that are available. The web address is: http://cc.ucsf.edu.

DT: It is hard to get a comprehensive listing of the trials that are available. Most are listed by institution. There are many organizations that are trying to compile a comprehensive list. For cancer there is the Cancer Information Service which covers all trials including alternative medicine. 1-800-4-CANCER will get you in touch with an actual person who will e-mail or fax you information on the clinical trials. The National Cancer Institute is setting up a patient friendly website called the PDQ for Alternative Medicine. The web address is: http://nccam.nih.gov. It will feature scientific, medical summaries on many different complementary and alternative medicine approaches.

DT: In China there is almost a dual system of medicine. Modern medicine is available in the big cities, so approximately 20-30% of the population have access to modern mammographic screening and surgery. Most medical centers do employ surgery, chemo and hormone therapy but not as aggressively as here. Most patients will seek, individually, traditional Chinese medicine as well. About 1 in 4 medical centers are attempting to integrate the two disciplines. We really do not know how these therapies compare relative to their effectiveness. We need better outcomes research.

DT: It is different and it is changing. In less industrialized countries the incidence is about one-fifth of what it is in this country. The rise is very rapid with industrialization. Clearly changes in lifestyle including diet, exercise, age of childbearing, are having an impact.

JC: This is a huge area of controversy. The protocol offered by Memorial Sloan Kettering to their patients is only light pressure massage. This is also true of the Charlotte Maxwell Clinic here in San Francisco. The reason for this may be liability issues and the fact that we do not have a definitive research base from which to answer how much pressure is good, where and when. Deep massage is sometimes necessary for the blood to get into the muscles, allowing them to relax, letting the patient get back into a restorative mode. At Commonweal, when a patient requests deep massage, we will call their physician. It is essential that the therapist be experienced, so that the massage does not result in damaged tissues.

BB: Historically, people did not want to take the chance that the cancer might spread to the lymphatic system.. The level of experience of the practitioner is critical. I believe that deep tissue massage is very beneficial for many women with cancer. The Osher Center has an ongoing study with massage in women undergoing chemotherapy addressing fatigue.

BB: There is no information to indicate that it does. It is probably most beneficial in terms of symptom management.

DT: Long-term side effects of therapy are very important to study. In the absence of clinical trials, we simply don’t know about the efficacy of herbal therapies. In my own practice I am open to alternative therapies but I give the patient guidelines: work with an experienced practitioner who can clearly articulate the benefits and side effects of a particular therapy. Then, use your common sense as to what is helping and what is not. Finally, there are some things that we know can be harmful, for example megadoses of fat-soluable vitamins like A, D and E, which should be avoided.

BB: I also think that it is important to evaluate the herbal therapies to achieve a balance and look at them relative to the medications the patient is currently taking.

BB: It’s really important to tell your physician what you are doing. I try to provide a list of the herbs for the patient to take to their physician. It provides a degree of safety and trust between practitioners.

BJ: The center has not been open for one-on-one treatments. Currently we run only yoga and stress reduction classes for people with cancer. In April, 2002, it can be accessed directly or by referral from your provider.

DT: This study was our attempt to do full integrative medicine. We were not attempting to study a single drug as is the usual scientific paradigm. Complementary medicine is individualized, so that each patient receives a different formula. We decided to take a "black box" approach, answering the question, "Is the therapy safe and do you see a response?" There was no control group, all patients had metastatic breast cancer. Dr. Yeshe Donden, former physician to the Dalai Lama, evaluated all the patients and prescribed the herbs he usually used. Conventional treatment was followed as usual: blood work, scans, and examinations were done in my office. We then looked for responses to the herbs. The FDA would only approve 7 formulas. We only enrolled 11 patients of the hoped for 30. The result showed no safety problems. Of the 9 patients who were evaluated, we found one patient with a temporary response, the other 8 had progression of their cancer. Our next step is to do an expanded study with all the herbs and a much larger number of patients. This will probably have to be done outside the U.S.

DT: There is no compelling data from any clinical trial that dietary modifications like vitamins, micronutrients, and soy, will help or hurt your chances of developing a recurrence of your cancer. There is still a lot of interest in studying anti-oxidants and soy. What may be more important if you are postmenopausal, is to exercise and maintain your body weight. A diet which includes cruciferous vegetables, cold water fish, green tea, and whole grains is beneficial.

BB: Similarly with Chinese medicine, the individualized diet would be recommended based on how the patient presents, if they have a specific imbalance. Focus on eating whole foods and you will be doing an excellent job of taking care of yourself.

DT: Flax seed does contain omega-3 fatty acids as well as lignands which seem to show some benefit in the research setting. There was a small Canadian study which looked at women on tamoxifen as well as flax seed oil. There was a suggestion that they had a higher response rate in the metastatic setting and a lower risk of recurrence. The study was small and certainly not definitive. (Be aware that there is a lot of fat in flax seed; 10-15 grams in a tablespoon, and the recommended dose is 3 tablespoons!)

BB: This is an herb used for relieving liver toxicity. It’s called a coursing or cleansing herb, which I use, but in conjunction with other herbs and not in high doses because it can give you diarrhea.

DT: Athough there is not yet any scientific evidence that it will help, this does not mean that it won’t benefit you. Some people do not have the luxury to wait for the scientific trials to be done.

BJ: I did a literature review and found that there were no studies with any kind of cancer. In laboratory studies, results indicated that it may work to regenerate the liver cells and to block toxins. Less significant is the antioxidant effect. From a scientific perspective, I don’t see how it would stop cancer from a different origin, but it definitely will cleanse the liver.

BB: It is really difficult to try to buy prescribed herbs when you have a serious condition like cancer without first talking to a practitioner. You should try to communicate with a practitioner over e-mail or telephone if there is nothing available in your area.

DT: Try to come up with a list of goals (help with fatigue or side effects, etc.), so that information or recommendations don’t overwhelm you.

BB: Certainly, this should not mean for the rest of your life, there should be a balance to treatment, something you can live with at a much lower level than during the course of cancer treatment. Essentially it is a case of how it benefits the individual.

BB: Some products can be extremely expensive, so cost should be weighed, but I recommend that my patients incorporate mushrooms into their diet.

DT: Polysaccharides do rev up the immune system. Much of the sugars are broken down in the stomach, but if the mushroom extracts can get through to the body they have a positive impact on t-cells. There is a debate as to whether this nonspecific stimulation is actually helpful. Studies have had mixed results.

DT: Glucose and other sugar metabolism in the body is very tightly regulated. Your ability to control it by what you eat is very limited. I personally do not subscribe to very stringent restrictions on refined sugar. Sugar levels go up based on breaking down glycogen in the liver—not based on what you eat.

BB: The effort to find a perfect, magical diet is the wrong direction. If the majority of the food you eat is healthy it will benefit you. A little enjoyment goes a long way.