Complementary Medicine in Cancer Therapy

1. Complementary Medicine in Cancer Therapy Patricia L. Judson, MD Associate Professor Gynecologic Oncology University of Minnesota

2. Categories of Methods • Mind, Body, Spirit • Manual Healing and Physical Touch • Herb, Vitamin and Mineral • Diet and Nutrition • Pharmacological and Biological

3. Aromatherapy Art Therapy Ayurveda Bioenergetics Biofeedback Breathwork Crystals Curanderismo Cymatic Therapy Dance Therapy Faith Healing Feng Shui Holistic Medicine Humor Therapy Hypnosis Imagery Kirlian Photography Labyrinth Walking Meditation Music Therapy Native American Healing Naturopathic Medicine Neuro-linguistic Programming Psychotherapy Qigong Samanism Spirituality and Prayer Support Groups Tai Chi Yoga Mind, Body, Spirit

4. Acupuncture Applied Kinesiology Biological Dentistry Bodywork Cancer Salves Castor Oil Chirpractic Cold Laser Therapy Colon Therapy Craniosacral Therapy Cupping Electroacupuncture Electrodermal Screening Electromagnetic Therapy Heat Therapy Hydrotherapy Hyperbaric Oxygen Therapy Light Therapy Magnetic Therapy Massage Moxibustion Myofascial release Myotherapy Neural therapy Ohashiatsu Osteopathy Polarity Therapy Psychic Surgery Reflexology Reiki Rosen Method Rubenfeld Synergy Method Sonopuncture Therapeutic Touch Transcutaneous Electrical Nerve Stimulation Tui-Na Watsu Manual Healing and Physical Touch

5. Aconite Aloe Alsihum Arnica Astragalus Aveloz Beta Carotene Betulinic Acid Black Cohosh Black Walnut Bromelain Calcium Capsicum Cat’s Claw Celandine Centella Cesium Chloride Chamomile Chaparral Chinese Herbal Medicine Chlorella Cloves Comfrey Copper Echinacea Essiac Tea Evening Primrose Flaxseed Flower Remedies Folic Acid Fu Zhen Therapy Germanium Ginger Ginkgo Ginseng Goldenseal Green tea Hansi Hoxsey Herbal treatment Indian Snakeroot Kampo Kava Larch Licorice Herbs, Vitamins and Minerals • Marijuana • Milk Thistle • Mistletoe • Molybdenum • Mugwort • Oleander Leaf • Orthomolecular medicine • Pau D’Arco • PC-SPES • Peppermint • Phytochemicals • Pokeweed • Potassium • Psyllium • Pycnogenol • Rabdosia Rubescens • Red Clover • Saw Palmetto • Selenium • Siberian Ginseng • Six Flavor Tea • St. John’s Wort

6. Acidophilus Amino Acids Broccoli Cassava Coriolus Versicolor Ellagic Acid Fasting Garlic Gerson Therapy Grapes Inositol Hexaphosphate Juicing Kombucha Tea Lycopene Macrobiotic Diet Maitake Mushroom Metabolic Therapy Modified Citrus Pectin Noni Plant Omega-3 Fatty Acids Selected Vegetable Soup Shiitake Mushroom Soybean Vegetarianism Wheat Grass Willard Water Diet and Nutrition

7. Antineoplaston Therapy Apitherapy Bovine Cartilage Cancell Cell Therapy Chelation Therapy Coenzyme Q10 Coley Toxins DHEADi Bella Therapy DMSOEnzyme Therapy Gamma Linolenic Acid Glucarate Greek Cancer Cure Homeopathy Hydrazine Sulfate Hydrogen Peroxide Therapy Immuno-Augmentive Therapy Inosine Pranobex Krebiozen Laetrile Lipoic Acid Live Flush Livingston-Wheeler Therapy Lyprinol Melatonin Oxygen Therapy Poly-MVA Pregnenolone Revici’s Guided Chemotherapy Sea Cucumber Shark Cartilage Shark Liver Oil Urotherapy 714-X Pharmacological / Biological

8. Tonight • My CAM research trial • Acupuncture • Botanicals, Vitamins, Minerals

9. Outcomes in Ovarian Cancer PatientsUsing Complementary Alternative Medicine

10. Newly diagnosed patients with ovarian & primary peritoneal cancer requiring chemotherapy  Eligibility criteria satisfied and consent process  Randomized Administer QOL instruments, cycles 1, 3, 6 Labs, cycles 1-6 Chart review / interview record complications Administer QOL six months post treatment

11. Clinical Hypnosis

12. Clinical Hypnosis Hypnosis has been defined as an altered state of consciousness resulting from the selective deployment of attention onto a focal goal and away from stimuli perceived as peripheral.

13. Clinical Hypnosis • As a therapeutic tool, hypnosis is intentionally induced • either by a therapist = hetero-hypnosis • or by the patient alone = self-hypnosis • Individuals retain control of themselves and their behavior while under hypnosis.

14. Clinical Hypnosis • Hypnosis has been associated with • positive changes in patient immunity • decreases in distress • decreased frequency and severity of treatment-related side effects • Prospective, randomized, controlled trials • psychological intervention, including hypnosis, can enhance the quality of life of patients with cancer • Hypnosis can enhance the immune response and increase T and B cell counts.

15. Clinical Hypnosis • Meta-analysis found that relaxation training and hypnosis with immune suggestions produced reliable, medium-sized increases in total salivary IgA concentrations. • Relaxation was unrelated to T cell and NK cell counts; these outcome data were not measured in the hypnosis studies.

16. Clinical Hypnosis • Women with breast or gynecological cancers • effectively reduce pain • decrease depression and anxiety • ameliorates chemotherapy side effects such as nausea and vomiting. • Self-hypnosis training for breast cancer survivors was associated with statistically significant (p<0.05) enhancements in perceived pain relief. • Related to decreased nausea and vomiting post chemotherapy, with decreases persisting after training visits with the therapist ended.

17. Clinical Hypnosis • Used to reduce anticipatory nausea in cancer patients • Although the data consistently find a positive relationship between hypnosis and outcomes, methodological shortcomings, particularly small sample sizes, lack of appropriate controls, lack of randomization, and failure to report outcome effect sizes support the need for further research

18. Massage Therapy • Manipulation, rubbing and kneading of the body’s muscle and soft tissue.

19. Massage Therapy • Studies have shown cellular changes in immune function following massage therapy. • 100% experienced reduced levels of anxiety • 56% experienced a substantial increase in white blood cell counts and natural killer T cells • Salivary IgA concentration significantly increased in an experimental group receiving a back massage compared to the control group • Bone marrow transplant patients receiving massage therapy compared to controls showed significantly larger reductions in distress, fatigue, nausea and anxiety, as measured by the State Anxiety Inventory

20. Healing Touch • Healing touch is a biofield therapy that is a holistic energy-based approach to health and healing. • It uses gentle, non-invasive touch to influence the human energy system, specifically the energy field that surrounds the body, and the energy centers that control the flow from the energy field to the physical body.

21. Healing Touch • The healing touch practitioner utilizes their hands to clear, energize, and balance the human energy fields. • The goal is to restore harmony and balance in the energy system supporting the patient in the self-healing process. • Healing touch complements conventional health care and is used in collaboration with other approaches to health and healing.

22. Healing Touch • Found to enhance the immune system and decrease anxiety • In one study, participants who received healing touch had significantly increased levels of IgA and IgM; CD25 and IgG levels were also increased in the healing touch group, but the differences were not statistically significant. • Healing touch has been shown to decrease anxiety levels in hospitalized patients. Patients who received the intervention by healing touch experienced a highly significant (p< .001) reduction in their state of anxiety according to a comparison of pre- and post-test means on the State Anxiety Inventory

23. Research Objective • To determine whether combined modality CAM used in ovarian or primary peritoneal cancer patients will change their QOL, immune status, use of anti-emetics, or hospitalizations while undergoing primary chemotherapy.

24. Research Objective • Primary Objective • Quality of Life: To determine whether QOL, as measured by the FACT-O and MHI total scores, is improved in patients receiving combined modality CAM as compared to patients receiving chemotherapy alone.

25. Research Objective • Secondary Objectives • To determine whether immunological changes in natural killer (NK) cells can be detected in patients undergoing primary chemotherapy with combined modality alternative therapies. • Evaluate for additional immunological response markers, chemotherapy side effects and complication rates change during combined modality alternative therapies treatment as determined by: • WBC with differential T and B panel (T helper cells, CD4, CD8) • Salivary IgA • Delays in chemotherapy protocol • Use of anti-emetics • Infection rate • Re-hospitalization rate

26. Questions?

27. Acupuncture • Penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. • Aims to restore and maintain health through the stimulation of specific points on the body

28. Acupuncture • According to TCM, health is achieved by maintaining the body in a "balanced state"; disease is due to an internal imbalance of yin and yang. • This imbalance leads to blockage in the flow of qi along pathways known as meridians. • Qi can be unblocked by using acupuncture at certain points on the body that connect with these meridians.

29. Acupuncture • No scientific evidence that acupuncture is effective as a treatment for cancer. • Relieves symptoms related to cancer and cancer therapies. • Effective for nausea caused by chemotherapy and anesthesia. • Effective for treating pain.

30. Acupuncture for hot flashes • 27 women electrostimulated acupuncture for 12 weeks – two 30 min sessions/wk for 2 wks then once weekly for the next 10 • Hot Flashes: • Baseline: 9.6 / 24hr • 12 weeks: 4.3 / 24hr • 1 year: 4.9 / 24hrs • 2 years: 2.1 / 24hr • 18 women HT for 24 months • Hot Flashes: • Baseline: 6.6 / 24hr • 12 weeks: 0

31. Botanicals, Vitamins, Minerals

32. Botanicals, Vitamins, Minerals • 38 million, 12% of Americans use botanicals*. • Among cancer patients in the US, up to 60% use herbal supplements. • Symptom control, quality of life, and cancer recurrence. • Research has expanded. *2002 National Health Interview Survey Centers for Disease Control and Prevention

33. Popular Botanical Agents • Essiac: burdock, turkey rhubarb, sorrel, and slippery elm. No anticancer effects. Stimulates the growth of human breast cancer cells1 • Iscador: a derivative of mistletoe. Many studies, no definitive benefit in cancer therapy. 1. Kulp KS et al. Breast Cancer Res Treat 2006;98(3):249-259

34. Popular Botanical Agents • Mushroom derived compounds: • Polysaccharide kureha (PSK), an extract of the mushroom Coriolus versicolor, or schizoplyllan. • Phase III trial of chemotherapy & radiotherapy +/- PSK found superior survival with PSK compared to controls in esophageal, gastric1-3 & colorectal cancers. 4-5 • Used after therapy in colorectal cancer prolonged survival by 1 year.6-7 • Results less encouraging for breast cancer & leukemia.8-10 • Niimoto M. et al. Jpn J Surg 1988;18(6)681-6. 2. Ogoshi K. et al. Cancer Invest • 1995;13(4)363-9. 3.Torisu M. et al. Cancer Immunol Immunother 1990;31(5)261-8 • 4-10 Available upon request

35. Popular Botanical Agents • PC-SPES: eight herbs from Chinese medicine. Reduce PSA, and improve QOL in men with advanced prostate cancer.1-4 • SV Soup – 19 vegetables from traditional Chinese medicine. NSCLC – enhanced survival by 11 months and improved QOL.5 • Small EJ et al. J Clin Oncol 2000;18(21):3595-603. • Pfeifer BL et al. BJU Int 2000;85(4):481-5. • Oh WK et al. Urology 2001;57(1):122-26. • Oh WK et al. J Clin Oncol 2004;22(18):3705-12 • 5. Sun AS et al. Nutr Cancer 1999;34(1)62-69

36. Herbal Products with Serious Side Effects* *Food and Drug Administration

37. Herbal Products with Serious Side Effects • Astragalus – can reverse the effects of cyclophosphamide. • Soy isoflavones may antagonize tamoxifen breast cancer prevention.

38. Long-term Use of Beta-Carotene, Retinol, Lycopene, and Lutein Supplements and Lung Cancer Risk: Results From the VITamins And Lifestyle (VITAL) Study. • 77,126 completed a detailed questionnaire about supplement use (duration, frequency, dose) during the previous 10 years. • 521 developed lung cancer • Longer duration of use of individual beta-carotene, retinol, & lutein supplements was associated with statistically significantly elevated risk of lung cancer • Little evidence for effect modification by gender or smoking status. • Conclusion: Long-term use of individual beta-carotene, retinol, and lutein supplements should not be recommended for lung cancer prevention, particularly among smokers. Satia JA, et al. Am J Epidemiol. 2009

39. Multivitamin use and risk of cancer and cardiovascular disease in the WHI cohorts. • 161,808 participants from the Women's Health Initiative • Detailed data were collected on multivitamin use at baseline and follow-up time points over a median of 8 years. • Documented cancers of the breast, colon/rectum, endometrium, kidney, bladder, stomach, ovary, and lung; CVD (myocardial infarction, stroke, and venous thromboembolism); and total mortality. • Results • 41.5% of the participants used multivitamins • 9619 cases of cancer, 8751 CVD events, 9865 deaths • Multivariate-adjusted analyses revealed no association of multivitamin use with risk of cancer.Ovarian Cancer: HR 1.07and 95% CI, 0.88-1.29 • Conclusion: multivitamin use has little or no influence on the risk of common cancers, CVD, or total mortality in PMP women. Neuhouser ML, et al. Arch Intern Med. 2009 Feb 9;169(3):294-304.

40. The role of antioxidants and vitamin A in ovarian cancer: results from the Women's Health Initiative • Examined the relationship between intake of dietary and supplemental antioxidant nutrients including vitamins C, E, and selenium as well as carotenoids and vitamin A and ovarian cancer • 133,614 postmenopausal women enrolled in the WHI study. • Dietary intake was assessed using a food frequency questionnaire, and ovarian cancer endpoints were centrally adjudicated. • 451 cases of invasive ovarian cancer were diagnosed over 8.3 yr of follow-up. • Results: Dietary intake at baseline was not significantly different for cases vs. controls. No significant relationships among dietary factors and ovarian cancer risk. • Conclusion: intake of dietary antioxidants, carotenoids, and vitamin A are not associated with a reduction in ovarian cancer risk. Thomson CA, et al. Nutr Cancer. 2008;60(6):710-9

41. Serum levels of vitamin D metabolites and breast cancer risk in the PLCO screening trial • Experimental and epidemiologic studies suggest that vitamin D metabolites (1,25-dihydroxyvitamin D and its precursor 25-hydroxyvitamin D) may reduce breast cancer risk. • Examined breast cancer risk related to serum levels of these metabolites. • Women ages 55 - 74 years, who donated blood at baseline in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial • 1,005 breast cancer cases during follow-up and 1,005 noncases were matched based on age and year of entry • Conclusion: In this prospective study of postmenopausal women, we did not observe an inverse association between circulating 25(OH)D or 1,25(OH)(2)D and breast cancer risk. Freedman DM, et al. Cancer Epidemiol Biomarkers Prev. 2008;17(4):889-94

42. Conclusion • The use of botanicals, vitamins, and minerals with cancer treatment is concerning. • Few studies have addressed dose levels, mechanism of action, safety or efficacy.

43. Thank You!