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WEDNESDAY October 8, 2003
"Investigating Complementary and Alternative Medicine:
What Works, What's New?"
Our special guests for the evening are Beverly Burns,
LAc, of the Osher Center for Integrative Medicine and the Charlotte Maxwell
Clinic, is a practitioner of traditional Chinese medicine (TCM); and Mary
Tagliaferri, M.D., LAc., Editor of Breast Cancer: Beyond Convention and the
co-creator of the complementary/alternative medicine program here at UCSF. Her
real interest is in integrative medicine research. BB: In the years between 1992 and 1997, there were
600 million individual visits to CAM practitioners compared to 400 million
visits to conventional medical doctors. The amount spent on research into
complementary medicine has increased from $3 million in 1993 to $113 million
today. The real need is to figure out how to do research in this area, how to
look at the systems of medicine that are available, and how to evaluate herbs.
It is almost impossible to evaluate individualized care and translate that into
evidence-based medicine. Most people seek out complementary medicine because
they want the engagement with the practitioner that is often lacking in western
medicine. The belief that CAM is going to change the long-term prognosis is
more pronounced when the disease is a serious one, like cancer. We must
separate what we believe from the absolute truth. It will be a very long time
before we can prove that it makes a difference in the long-term outcome. Chinese
medicine is an entire system of medicine. It looks at disease as an imbalance
that comes from many difference sources. The diagnosis is the most important
piece in terms of the treatment that will then be provided. The tools for the
treatment are acupuncture, food therapy and movement therapy. A practitioner
should be able to diagnose the patient and develop a treatment plan that
incorporates all these things. Therapeutic movement like tai chi or yoga
definitely improves the quality of your life. Acupuncture has been proven to be
effective for chemotherapy-induced nausea, fatigue, post surgical pain, and for
metastatic bone pain. In the U.S. we have a tendency to use one herb in many
different situations, which is not traditional practice. Herbs are much more
effective in combinations, depending on the synergy. Concerns should include
toxicity and herb interactions. Some herbs can increase or decrease the
interaction with drugs. This can be very dangerous. When you realize that you
are dealing with between 350 and 450 different kinds of herbs used by Chinese
practitioners, you can see that the quality and experience of the practitioner
is very important. As you look at products, particularly supplements, try to
find out who does the research. If it is the manufacturer, realize that this
represents a conflict of interest. While we can’t yet promise that
complementary medicine influences outcome of disease (and beware of
practitioners that do!), we do know that it strongly influences quality of
life. Also, don’t worry about placebo vs. herb effect. If you are getting a
positive benefit, that can be healing, even in terms of your physical health. MT: For me, the important thing with cancer
treatment is not when your breast will get better, but when will you heal yourself.
More specifically, I want to speak about the benefits of soy, even with ER+
women. Soy was first investigated when people began to compare Japanese culture
to American culture relative to Japan’s dramatically lower rate of breast
cancer and death from breast cancer. These rates increased when Japanese women
moved to the West. But if soy is estrogenic, it should be a problem for women
with estrogen receptor positive breast cancers. In 1986, the first estrogen
receptor (alpha) was discovered. Tamoxifen
blocks the alpha-receptor, not allowing the genes to proliferate into
cancer. In 1996, a second estrogen
receptor (beta) was discovered. Because many of the proteins that bind to it
are different, the beta-receptor shuts off cell proliferation rather than allow
it. Estradiol, a component of hormone replacement therapy, is found in
alpha-receptors. Genestine is the main protein found in soy. There is also
tissue selectivity to these receptors: more alpha in the uterus and breast,
which prepares for pregnancy. Beta is more commonly found in the brain and the
bone, which is why phytoestrogen like soy can help control hot flashes and
maintain bone mass without causing breast tissue proliferation. This is based
on empirical findings, but it is important to note that Western medicine
practices evidence based medicine only part of the time, the rest is empirical,
like complementary and alternative medicine. What do you do if you have hot flashes? Of
postmenopausal women with a history of breast cancer who are on tamoxifen up to
80% do have hot flashes, many severe enough to discontinue treatment. Megase
has been found to be very effective, but causes weight gain. Anti-depressants
have many side effects. Herbalists encourage women to take phytoestrogens like
soy. There is no evidence that taking soy as a food increases breast cancer
risk, but also no real evidence at this time to support that it helps. MT: There is evidence that soy is protective, and
there has not been one deleterious trial on humans. You could not possibly eat
enough soy to make it a problem. Since heart disease is the leading cause of
death for women, it is important to note that soy definitely has been found to
lower cholesterol. We have just completed a 30-day study looking at the effects
of a 22-herb medicine to decrease hot flashes in healthy women. There were no
increases in estradiol levels in these women over the course of the 30-day
trial, with a slight decrease in the incidence of hot flashes. HR: If you look at the ATAC trial data, comparing
anastrazole (Arimidex) to tamoxifen, it looks like only about 34% of women get
hot flashes with Arimidex and 39% with tamoxifen. In our clinical practice, we
seem to see much greater reporting of hot flashes that disrupt daily life.
Black cohosh did not decrease hot flashes in reported trials, but many patients
report success with its use. MT: The effect of phytoestrogens is most dramatic
in the premenopausal woman. It may be that soy plays a role in the way tissue
is laid down in the breast. This will be especially true with adolescents who
are exposed at a younger age. Experiments with rats have shown that the earlier
you start with soy, the more protective it is. HR: The down regulation of the estrogen receptor
is an exploding area of research. UCSF and Marin Breast Cancer Watch have just
jointly received a large NCI Environmental Health Grant to study adolescent
risk factors like diet and environment which might play a role in the
development of breast cancer. What we don’t want to do is induce estrogen
receptor blockade resistance because that may generate a more resistant form of
breast cancer recurrence. MT: Currently there are no beta selective drugs.
Western medicine will be working on developing these drugs. Currently our
staining is only for ER-alpha. What about taking drugs like raloxifene and tamoxifen
in combination? Giving drugs like these for more than 5 years may actually
make the cancer more resistant, potentially using that agent as a growth
factor. Giving drugs in combination may alter metabolism as well as the binding
of the drug to the estrogen receptor, actually making it act as an estrogen. What about taking herbs during therapy? St. John’s
Wort is the most studied herb in this context. It was initially found to have
anti-depressive properties. It also changed the metabolism of anti-retroviral
therapy used for AIDS, so that the drugs became less effective. It was also
found to increase the metabolism of a cancer drug used for colorectal cancer.
It doesn’t work in the same way for all drugs, so you must pay attention to
dosage. Why don’t physicians prescribe herbs? It’s an
entirely different system of medicine. Your doctor would have to go to school
for another four years. A better goal is to try to integrate it into Western
medicine, so that experienced providers from both arenas are working together. Are there contraindications to taking Omega 3 and 6
with tamoxifen? Both should be taken as a fish oil with food in order to
assimilate. Fatty acids are valuable for the heart and the brain. Store in the
freezer. What about flaxseed? Ground as a food it is very helpful to eliminate the constipation that
may be caused by the cancer drugs you are taking. A very small study with a
mouse model showed that it might cause proliferation of metastases in other
areas. Is it better to incorporate cruciferous
vegetables into your diet rather than as a supplement? Yes, if 90% of the time you eat whole
vegetables and grains and fish and meat that is hormone free, it is very
beneficial to your health, but people don’t do that. Supplements are not
regulated, so you must exercise caution. What is the difference between Chinese and
Tibetan medicine? They are similar
but at the same time drastically different. The method of diagnosis is similar:
collecting information by asking questions, feeling pulse and looking at tongue
to come up with the diagnosis. The herbs used are very different, as the
climates of the individual countries are different. There is not a lot of
breast cancer in Tibet. In China, as early as 400 B.C. the literature refers to
swellings and ulcerations, with specific treatments. Many Chinese herbs have
been found to be anti-cancerous. Some Internet resources with good
information about CAM: www.mdanderson.org/departments/cimerrosenthal www.ucsfbreastcarecenter.org (look for link under “clinical trials”) Next meeting is
Wednesday, November 5, 2003. Topic: “Demystifying Breast Cancer Surgery: From
Sentinel Nodes to Reconstruction” |
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