Integrative Approaches to Symptom Management in Breast Cancer Patients
An increasing number of breast cancer patients are using integrative medicine approaches to manage symptoms associated with cancer or its treatment. Studies indicate that there is a high prevalence of complementary and integrative medicine (CIM) use among cancer survivors. A population-based study of 1,471 patients showed that 66% of cancer survivors used CIM in their lifetime, and 43% used CIM in the last 12 months (1). General disease prevention, immune enhancement, and pain were identified as the top three reasons for CIM use. Compared to the general population, cancer survivors were more likely to use a CIM therapy if it was recommended by their provider and were also more likely to disclose CIM use to their providers (1). While patients seek informed advice and communication from their physician on this subject, at the same time they believe that physicians have limited knowledge on the topic and no interest in discussing its use (2). Cancer patients who experience unmet needs from their health care team throughout survivorship are more likely to seek out CIM to address those needs (3). From a clinical perspective, symptom management is also integral to the successful implementation of cancer care: addressing symptoms supports patient adherence to prescribed treatments and follow-up plans, and fosters a patient’s return to a state of well-being, whereas failure to address these issues can lessen the impact of mainstream therapies due to decreased compliance, leading to worse outcomes (4,5).
Therefore, it is important for health care providers to have some basic knowledge of CIM to facilitate an open dialog about what patients may be using and to offer appropriate guidance. This chapter provides an overview of the integrative therapies clinically used for symptom management in patients with breast cancer.
THE ROLES OF INTEGRATIVE MEDICINE IN CANCER SUPPORTIVE CARE
Cancer treatments often produce difficult physical and emotional symptoms, and late or long-term effects are common (5,6). Symptoms can also be related to age, comorbidities, or the cancer diagnosis itself, and have multifactorial etiologies (7). Symptom relief is therefore commonly sought both during treatment and throughout survivorship.
Complementary and integrative medicine has grown to replace the term “complementary and alternative medicine” (CAM) to reflect the incorporation of evidence-based complementary modalities into mainstream cancer care (4,8). Integrative medicine uses nonpharmacologic therapies adjunctively to address symptoms safely and effectively, improve quality of life (QoL), and facilitate lifestyle changes. A number of symptoms can be controlled or improved with integrative therapies including anxiety, depression, stress, fatigue, feelings of isolation, hot flashes, lymphedema, nausea, neuropathy, pain, perioperative symptoms, sexual dysfunction, physical deconditioning, dyspnea, urinary problems, and xerostomia.
Four main types of integrative approaches are clinically used to help breast cancer patients manage symptoms associated with the disease and its treatment: diet and exercise recommendations, mind–body techniques such as yoga and meditation, individualized therapies such as acupuncture and massage, and the use of dietary supplements.
The World Cancer Research Foundation describes diets linked to increased cancer risk as those that include the regular consumption of red and/or processed meats, alcoholic drinks, and foods containing refined sugars (9). Diets linked to decreases in cancer risk include foods containing dietary fiber, fruits, nonstarchy vegetables, and those containing vitamin D such as salmon, sardines, and some fortified foods. As such, the recommended diet for cancer patients and survivors includes a diverse and balanced diet, with an emphasis on plant-based foods from natural sources. For breast cancer survivors, we usually encourage eating 3 to 5 servings of nonstarchy vegetables per day and 2 to 4 servings of nonsweet fruits a day. It is also important to ask the patient to eat a variety of foods: plant-based proteins such as beans, peas, lentils, and nuts; animal proteins such as lean poultry, fatty fish including salmon and sardines, and low-fat dairy; and whole grains such as oats, bulgur, and high-fiber breads and cereals (10). We usually recommend that patients limit red meat to 1 to 2 servings per week, with each serving being fist size (approximately 3 ounces). We also recommend that patients avoid processed meats, limit alcohol intake, and eliminate white sugar, high-fructose corn syrup, and artificial sweeteners as much as possible.
Most of these dietary recommendations stem from epidemiological studies. A randomized controlled trial (RCT) known as PREDIMED showed that a heart-healthy Mediterranean diet may reduce breast cancer risk (11). In this study, 4,282 women aged 60 to 80 years who were at high risk for cardiovascular disease were randomized to either a Mediterranean diet supplemented with extra-virgin olive oil (EVOO), a Mediterranean diet supplemented with mixed nuts, or a low-fat diet serving as the control group. After a median follow-up of 4.8 years, 35 patients were diagnosed with breast cancer. Participants in the Mediterranean diet/EVOO group had the lowest incidence of breast cancer (1.1 per 1,000 person-years), compared to the nut-supplemented Mediterranean diet, or low-fat control group (1.8 and 2.9 per 1,000 person-years, respectively) (11). This is the first RCT to demonstrate an effect on breast cancer incidence from the implementation of a long-term diet, suggesting benefits from following a Mediterranean/EVOO-supplemented diet for the primary prevention of breast cancer. The Mediterranean diet consists of a variety of fruits, vegetables, cereals, legumes, poultry, fish, nuts, seeds, olive oil, moderate intake of red wine with meals, and low consumption of meat and dairy products.
In addition, several prospective cohort studies conducted in women after breast cancer diagnosis and treatment showed that a diet high in fruits, vegetables, whole grains, poultry, and fish was associated with better survival when compared to a diet high in refined grains, red and processed meats, desserts, high-fat dairy, and French fries (12,13). Table 10.1 highlights important recommendations for cancer patients both during treatment and throughout survivorship (10).
Table 10.1 Dietary Guidance for Cancer Survivors
• Whole foods: emphasize plant-based foods
• Nonstarchy vegetables: 3–5 servings daily*
• Nonsweet fruits: 2–4 servings daily*
• Vary protein sources
▪ Beans, peas, lentils, and nuts
▪ Lean poultry, fatty fish including salmon and sardines, and low-fat dairy
• Choose whole grains
Oats, bulgur, whole wheat, high-fiber breads and cereals
• Rinse all produce thoroughly with clean water
Whether organic or conventional
• Red meat: 1–2 fist-size servings weekly (approximately 3 oz)
• Alcohol: less than 1 drink daily
Avoid when possible
• Processed meats
• Refined sugars: white sugar, high-fructose corn syrup
• Artificial sweeteners
*1 serving = 1 cup of dark leafy greens or berries, 1 medium fruit, or 1/2 cup of other colorful fruits and vegetables.
Source: From Ref. (10). National Comprehensive Cancer Network. Nutrition for cancer survivors. www.nccn.org/patients/resources/life_after_cancer/nutrition.aspx
ORGANIC VERSUS CONVENTIONAL
A common question among cancer patients is whether or not organic foods are better than conventional sources. Current research on this subject has been mixed (14–19), and not without polarizing debate. Recently, a large prospective study indicated that the consumption of organic food had either little or no effect on cancer incidence, with the possible exception of non-Hodgkin’s lymphoma (20). However, organic choices may reduce exposure to pesticide residues and antibiotic-resistant bacteria (15). Still, given that (a) the more likely issue for many cancer patients is the adoption of a diet emphasizing a variety of whole foods in the first place, (b) the evidence on organic versus conventional foods is fluid, and (c) accessibility is confounded by marketing practices, regions, price points, and availability, patients should rather be encouraged to focus on incorporating the best possible sources of whole foods available to them, and to rinse produce thoroughly with clean water before eating, whether organic or conventional.
Although there are currently no clinical trials to suggest that sugar helps cancer grow and progress, one study does suggest associations between high sugar intake and breast cancer risk (21). In recent animal studies that mimicked conditions of the human Western diet, a clear risk between increased sugar consumption and breast cancer occurrence, tumor growth, and metastasis was also demonstrated (22). Investigators determined that fructose in particular, as available in table sugar and high-fructose corn syrup, appeared to be responsible for facilitating lung metastasis and 12-hydroxyeicosatetraenoic acid (12-HETE) production in breast tumors. Added sugars also contribute significant amounts of calories, which can cause weight gain, a risk factor for breast (23,24) and other cancers (25), diabetes and Alzheimer’s disease (26), and mortality from cardiovascular disease (27). The American Heart Association currently recommends that women with moderate activity levels consume no more than five teaspoons of added sugar daily, and that sedentary women limit their intake even more, to the equivalent of three teaspoons daily (28).
Research has also shown a direct correlation between alcohol intake and risk of breast cancer. Reanalysis of data on 58,515 women with breast cancer and 95,067 women without the disease from 53 epidemiological studies showed that the relative risk of breast cancer was 1.32 (1.19–1.45; P < .00001) for an intake of 35 to 44 g (2.2–3.2 drinks) per day, and 1.46 (1.33–1.61; P < .00001) for ≥45 g per day compared to women who reported drinking no alcohol. Relative risk increased by 7.1% (95% CI 5.5%–8.7%; P < .00001) for each additional 10 g intake per day (ie, for each extra unit or drink of alcohol consumed daily) (29). Therefore, and also in accordance with National Comprehensive Cancer Network risk reduction guidelines (30), we usually recommend that breast cancer survivors limit their alcohol intake to less than 1 drink per day (equivalent to 1 oz of liquor, 6 oz wine, or 8 oz beer).
Isoflavones, a type of phytoestrogen, are found in some foods, most notably soy products. These naturally occurring compounds have been shown to have antioxidant and free-radical scavenging activities, but such properties may be altered by their metabolism in the human body (31,32). In addition, there are many questions about whether soy products actually increase or decrease breast cancer risk. A 2014 meta-analysis of 35 studies on the association between soy isoflavone intake and breast cancer risk suggests a lower risk for both pre- and postmenopausal women in Asian countries, but no influence on risk for women in Western countries (33). Consequently in general, we do not instruct patients to “avoid soy” or reduce whole soy foods (eg, tofu, edamame, miso, soymilk) as there is no evidence to suggest that eating them at practical levels increases breast cancer risk or recurrence in humans.
Exercise and Physical Activity
Sitting for many hours daily is a known independent risk factor for cancers of the colon, endometrium, and lung (34). In addition, sedentary lifestyle contributes to obesity, and there are well-established links between obesity and many types of cancer (35,36). Even more specifically, weight gain and obesity are risk factors for the development of postmenopausal breast cancer (37,38), while physical activity is associated with improvements in cancer-related survival (39–41).
Publications in the oncology literature, therefore, recommend exercise as part of survivorship self-care (30,42–44). In addition, exercise and physical activity can help to relieve or reduce symptoms that are often of multifactorial etiology, including pain (45,46), such as aromatase inhibitor (AI) induced arthralgia (47), fatigue (46,48–50), physical deconditioning (48,51–55), and nausea/vomiting (45), any of which may contribute to the interruption or even cessation of cancer treatment regimens (56). For breast cancer patients, additional side effects from treatment such as bone loss (57,58), weight gain (57,59), and hot flashes (60) may also be decreased with established exercise regimens.
Table 10.2 highlights important recommendations for cancer patients both during treatment and throughout survivorship (61). At our institution, we usually recommend that breast cancer survivors do some type of moderate exercise for at least 30 minutes daily, with the goal of at least 300 minutes per week.
Mind–body modalities recognize the inherent and reciprocal relationship between physical and psychological states, and that physical well-being may be modulated via neurohormonal and immunological pathways. Along with diet and exercise, they are among the most effective therapies to affect positive change in emotional and psychological profiles among cancer patients.
The most commonly practiced and scientifically studied among breast cancer survivors are meditation, yoga, and tai chi/qigong, which are used to address emotional self-regulation, anxiety, and depression, as well as cognitive impairment, sleep disturbance, and balance issues. Broadly speaking, there is more overlap than distinction among these practices as adopted attitudes of relaxed, open awareness without goal orientation, both in movement and stillness, lead to reclaimed states of physical, emotional, and mental well-being. In the case of yoga, tai chi, and qigong as movement arts and depending on the level of activity, there are also benefits similar to exercise.
Several approaches to meditation have been described (62–64). Methods of focused attention meditation include voluntary mental immersion on a chosen object, with nonjudgmental detection and disengagement from distraction, and a gentle return or redirection to the intended object. Another style, open monitoring meditation, involves nonreactive observation of the content of one’s experience and how that may change from moment to moment. The potential regulatory functions of these practices on attention and emotion processes could have a long-term impact on the brain and behavior.
Table 10.2 Physical Activity Recommendations for Cancer Survivors
• Avoid inactivity
• Exercise: can include daily routines and recreational activities that would also be described as physical activity
• Tailor activities to individual:
Abilities → reduces injury
Preferences → increases compliance
• Incorporate activity of at least:
150 min of moderate intensity
75 min of vigorous intensity, if possible
• Strength training:
2–3 times weekly
Include major muscle groups
• Stretch major muscle groups regularly
Source: From Ref. (61). National Comprehensive Cancer Network. NCCN guidelines: survivorship, Version 2.2015. www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf
Mindfulness-based stress reduction (MBSR) is a form of meditation that has been rapidly adopted in cancer clinical practice. It uses a combination of mindfulness meditation, yoga, and body awareness to help people become more mindful and reduce stress. Studies of MBSR in breast cancer patients indicate those who practice regularly experience significantly lower depression, anxiety, and fear of recurrence, as well as higher energy and physical functioning compared to usual care (65). Further, the benefits of MBSR on psychosocial adjustment go beyond that of credible controls and are universal across levels of expectation to its efficacy (66). Clinically meaningful, statistically significant effects on depression and anxiety have also been demonstrated after 12 months of follow-up, with medium-to-large effect sizes (67). Improvements in endocrine-treatment-related side effects (68), sleep quality immediately postintervention (69), cortisol profiles, and hypothalamic–pituitary–adrenal (HPA) axis functioning, as well as maintenance of telomere length, have also been noted (70–72). Similarly, studies evaluating a mindfulness-based cancer recovery (MBCR) program indicate this intervention is better for treating distress and stress, and improving QoL, in breast cancer survivors compared to supportive–expressive group therapy (73). It also demonstrated noninferiority in some measures for treatment of insomnia compared to cognitive behavioral therapy (63). A brief, mindfulness-based intervention for younger breast cancer survivors also suggests efficacy for the reduction of behavioral symptoms and proinflammatory signaling (74).
Yoga is a traditional Indian practice that incorporates breathing exercises (pranayama) and movement through postures or holding of postures (asanas). It has been shown to reduce stress and improve QoL, memory, and sleep quality in cancer survivors (75–79). In breast cancer patients, yoga improves range of motion (80) and social functioning and mood, as well as reduces stress (81–83), anxiety (84), and a range of other psychological symptoms (73). In survivors with persistent fatigue and treatment-induced or exacerbated menopausal symptoms, yoga reduces fatigue, joint pain, and number of hot flashes while increasing vigor, with benefits persisting at 3-month follow-up (85,86).
Both qigong and tai chi are based on traditional Chinese medicine (TCM) theory. They use precise movement sequences, meditation, and synchronized breathing to restore the flow of qi (chi, internal energy). These practices have significant impact on sleep dysfunction, anxiety, depression, mood, fear of falling, and QoL (87–90). Improvements in aerobic capacity, muscular strength, and flexibility (91); balance, cognitive functioning, cancer pain, fatigue, numbness, and dizziness (87,92,93); and reduced markers of inflammation (93,94) have also been demonstrated. As a moderate weight-bearing exercise, preliminary data indicate that tai chi may also exert positive effects on markers of bone metabolism (95), as well as insulin and cytokine levels associated with lean body mass (96).
Although initial instruction is required, mind–body approaches are largely self-administered, low-cost, effective, and safe, with minimal to no side effects, and are therefore highly recommended for cancer patients.
Acupuncture is a TCM technique that involves inserting and manipulating filiform needles into specific points on the body to alleviate symptoms. Although its mechanisms are not fully established, acupuncture appears to interact with and modulate the functioning of nerves, neurotransmitters, and neurohormones (97–100). Two methods of acupuncture stimulation are clinically used. In manual acupuncture, needles are inserted and rotated by the practitioner to achieve a de qui sensation (duh chee; soreness, fullness, heaviness, or local area distension) (101,102), while electroacupuncture (EA) refers to the added use of mild to moderate electrical current through inserted needles to stimulate acupuncture points.
Acupuncture has been used as a complementary therapy to treat a wide range of conditions experienced by breast cancer survivors. Growing evidence suggests that acupuncture may be beneficial for cancer-treatment-induced symptoms including musculoskeletal symptoms, hot flashes, lymphedema, peripheral neuropathy (PN), fatigue, anxiety, and depression.
MANAGEMENT OF AROMATASE INHIBITOR-INDUCED MUSCULOSKELETAL SYMPTOMS (AIMSS)
AIs are the recommended first-line adjuvant endocrine therapy in postmenopausal women with hormone-receptor-positive breast cancer, either as monotherapy or in sequence with tamoxifen (103). AIMSS are reported in up to 50% of women, leading to drug discontinuation in approximately 13% of users (104,105). Maximum benefit is observed with 5 years of adjuvant endocrine therapy and is therefore the recommended duration of treatment for breast cancer survivors. Current interventions for AIMSS including oral analgesics and exercise have limited efficacy (106,107), in addition to the fact that long-term use of the former is challenging.
To date there have been four RCTs comparing the effects of real acupuncture (RA) and sham acupuncture (SA) in reducing AIMSS symptoms, with no significant adverse reactions to either treatment (108–111). Although one of the trials (108) indicates that RA may be significantly better for joint muscle pain than SA, this finding was not confirmed by the other three. Mao et al (111) is the only study among these with an added waitlist control arm showing statistically significant greater pain reductions with RA. An ongoing three-arm Southwest Oncology Group study (112) with a sample size of 228 patients may further clarify the role of acupuncture in helping breast cancer survivors with AIMSS (112). For now, it may be reasonable to suggest that breast cancer patients try acupuncture for AIMSS, as it has minimal risk and potentially carries significant benefits.
CONTROL OF VASOMOTOR SYMPTOMS
Vasomotor symptoms such as hot flashes and night sweats are other common symptoms that result from breast-cancer-related treatments including chemotherapy or estrogen deprivation therapy-induced menopause. The management of hot flashes among breast cancer survivors is challenging, as the most effective treatment, estrogen therapy, is associated with increased risk of breast cancer recurrence and development of new breast cancers. Acupuncture shows promise as a therapeutic approach for hot flashes with minimal side effects in women with breast cancer across several RCTs (113–116). A recent systematic review of acupuncture to control hot flashes in cancer patients showed significant improvements from baseline in all eight studies evaluated, and that RA was significantly better than SA for different aspects of hot flashes in three studies (117). However, none of the studies were rated with a low risk of bias, making the current evidence insufficient to either support or refute the use of acupuncture for hot flashes.
Treatment-induced lymphedema may be a lifelong concern for some breast cancer survivors. Up to 22% of patients suffer from this complication even with conservative surgical approaches, while it occurs more commonly in patients who undergo more extensive surgical procedures and radiation therapy (118–120). Lymphedema presents as chronic, persistent swelling in the affected extremity, causing increased risk of infection, pain, immobility, and worsened body image and QoL. The mainstay of treatment is a nonpharmacologic intervention known as complete decongestive therapy (CDT), which has four major components: manual lymph drainage, compression bandaging, compression garments, and exercise. Manual lymph drainage involves the movement of lymphatic fluid from the nonfunctioning region to a nearby region that drains effectively. Compression bandaging involves applying multiple layers of short stretch bandages from distal to proximal regions in order to promote lymphatic fluid movement. Compression garments are then applied with a steady pressure of 20 to 60 mmHg to prevent lymphedema recurrence. Upper body exercises may also reduce risk and severity (121). These treatments are labor-intensive, have limited efficacy, and are estimated to cost $10,000 per year per patient (122).
Previous case reports, retrospective chart reviews, and pilot studies have demonstrated acupuncture to be safe and potentially effective in reducing swelling and improving both upper and lower extremity edema (123–126). Among them, a 2013 study was the largest (n = 33), well-designed single-arm trial to evaluate acupuncture safety and efficacy in patients with moderate to severe chronic breast-cancer-related lymphedema (BCRL) (126). No serious adverse events were reported after a total of 255 acupuncture sessions. Twelve of thirty-three evaluable patients reported mild bruising or minor pain/tingling in the arm, shoulder, or acupuncture site at least once. Importantly, no infections were reported even though the standard acupuncture treatment protocol involves inserting four acupuncture needles in the limb with lymphedema. In addition, even though this was not an RCT, a mean reduction of 0.90 cm in arm circumference was demonstrated, and 11 patients (33%) experienced a ≥30% relative reduction in the difference between arm circumferences from baseline to postintervention. The same research group is conducting an RCT to further determine the efficacy of acupuncture in reducing BCRL symptoms.
The use of acupuncture to treat lymphedema is controversial as placing needles in the affected area is considered contraindicated by most breast oncologists and lymphedema experts due to concerns about infection and worsening the condition. To date, these negative outcomes have not been reported in pilot studies, which is encouraging, but may also be due to small sample size. Therefore, the recommendation is still to avoid placing acupuncture needles in the extremity with lymphedema outside of clinical trial settings.
Several clinical trials demonstrate benefits with acupuncture in reducing neuropathic pain in cancer patients (127–130). Among them, one clinical trial showed the effectiveness of auricular acupuncture for cancer-treatment-induced neuropathic pain (128). Patients were randomized to either real auricular acupuncture at active points or one of two placebo arms (real auricular acupuncture at placebo points, or SA through auricular seeds at placebo points). Pain intensity decreased by 36% in the active intervention group at the end of 2 months compared to baseline, whereas both placebo groups experienced only a 2% decrease in pain intensity (P < .0001) (128). In a study of acupuncture versus best medical care (BMC) for PN, a majority of patients in the acupuncture group (76%) had improvement in symptoms and nerve conduction studies compared to only 15% in the BMC group (131). In addition, investigators found full correlation between symptom improvement and nerve conduction studies (131). Although PN etiology was either unknown or due to diabetes, investigators found comparable results for patients with chemotherapy-induced PN (132).
Another debilitating side effect of radiation and/or chemotherapy with no effective treatment options is fatigue. To address this problem, a large RCT was conducted to evaluate the effects of acupuncture plus usual care versus usual care alone for breast-cancer-related fatigue in 302 patients (133). The mean general fatigue score was significantly lower in those who received six weekly acupuncture treatments compared to those who did not (−3.11 on a 0–20 scale). In addition, acupuncture improved specific aspects of fatigue such as physical and mental fatigue, anxiety, and depression, and improved patients’ QoL (133). Although mechanisms were not elucidated and the study design lacked a placebo control, the results are consistent with existing literature (134,135). Another well-designed but smaller RCT that evaluated EA for fatigue, sleep, and psychological distress in breast cancer patients with AI-related arthralgia did include both wait-listed controls (WLCs) and an SA arm. Compared to usual care, EA produced significantly and clinically relevant improvements in fatigue, anxiety, and depression, while SA improved only depression (136).
Taken together, current research suggests that acupuncture may be a valuable and safe nonpharmacological modality to treat various symptoms and improve QoL in breast cancer survivors, but these preliminary findings should be confirmed in larger trials with longer follow-up.
A number of studies have evaluated the effects of massage on cancer patients. Although many have been preliminary or of mixed quality, there are recurring themes of improved QoL and clinically meaningful reductions in pain, anxiety, and stress. A recent meta-analysis suggests there is mild evidence that massage may help to address negative emotions and fatigue in patients with breast cancer (137). Another meta-analysis found massage to be effective in relieving cancer pain, and especially surgery-related pain, with foot reflexology more effective than body or aroma massage (138). A multidimensional program that included strengthening exercises and massage as major components improved neck and shoulder pain and reduced widespread pressure hyperalgesia in breast cancer survivors compared to usual care treatment (139).
In a large sample of women with advanced-stage breast cancer receiving chemotherapy and/or hormonal therapy, investigators determined there were significant improvements in physical functioning and dyspnea severity with reflexology when compared to both a lay foot manipulation group and conventional care (140). Studies have also found benefit for patients with terminal cancer to improve pain, mood, and sleep quality (141,142). A study evaluating an abdominal massage intervention for end-stage cancer patients also found a significant group-by-time interaction on depression, anxiety, poor well-being, and perceived abdominal bloating (143).
Given that survivors have unique needs at different stages of disease, it is important for patients to have access to massage therapists who are specially trained in working with cancer patients. At the same time, certain types of massage may be safely given by caregivers who are specially trained on safe therapeutic touch. A recent study found a model of massage intervention using a multimedia caregiver education program to be feasible while decreasing patient pain, depression, and other symptoms (144). For many patients, massage therapy is a useful therapeutic tool to manage cancer symptoms, and is included among the services available at our institution both on an inpatient and outpatient basis. We also offer online and monthly demonstrations to provide caregivers with the knowledge and confidence to provide safe and effective touch therapy at home.
Supplements and Botanical Products
The issue of supplement use, especially among those who are undergoing treatment, is an important topic to address with patients. Supplement manufacturers are not required to have standards for the safety, content, and quality of their products, and possible side effects are not included in labeling. One of the most important messages to patients should be the encouragement of a well-balanced diet as previously described to obtain the right amounts of vitamins, minerals, and antioxidants, as well as micronutrients, which are lost when one relies on supplements. Further, supplement use during cancer treatments may result in perioperative complications, or interact with chemotherapy or radiation to cause serious side effects or reduce treatment efficacy.
A popular example is turmeric, a plant that is native to South Asia but cultivated around the world and used in traditional medicine for improving circulation and digestion. Turmeric extracts have been marketed for memory problems, arthritis, and cancer prevention. Because the active ingredient of turmeric, curcumin, is known to interfere with cytochrome P450 enzymes (145,146) and may interact with chemotherapy drugs like cyclophosphamide and doxorubicin (147), we advise patients not to take turmeric or curcumin during chemotherapy or hormonal therapy due to herb–drug interaction concerns. Many other herbal supplements can fall under this category, including St. John’s wort, green tea extract, and astragalus. AboutHerbs.com (148) is a free resource for both health care professionals and consumers provided by Memorial Sloan Kettering, which outlines the current evidence for various supplements that are of interest to cancer patients including potential interactions and side effects.
In some instances, however, it can be difficult to obtain a nutrient from diet alone. Such is the case with vitamin D, which in addition to helping bone formation has been reported to be a pro-differentiation hormone (149) with antiproliferative (150), anti-inflammatory, and immune-regulatory effects (151). Epidemiological studies show that vitamin D from sunlight exposure and dietary intake may have protective effects against breast cancer (152,153), and data correlate with observations that many breast cancer survivors are vitamin-D-deficient (154). As such, we monitor patients’ vitamin D levels and recommend supplementation in patients with low serum levels accordingly.
Diet and exercise recommendations are important components to integrate into mainstream cancer care. A majority of breast cancer survivors may be obese or overweight, with greater risks for recurrence, cardiovascular disease, diabetes, and overall poorer QoL (155), and many women report initiating dietary changes during active treatment (156). A number of cancer-treatment-related side effects can also be addressed with integrative therapies such as acupuncture, massage, and mind–body therapies, and cancer patients often seek advice from their health care providers on which modalities may be most effective for them. Table 10.3 provides a general overview of integrative modalities that are clinically practiced in breast cancer symptom management, and Table 10.4 provides links to trusted online sources on integrative therapies for health care professionals and consumers.
A referral system to integrative therapy programs such as exists at our institution is vital to ensure continuity of care for patients with unique and changing issues in their health status. Indeed, the provision of such structure, guidance, support, and feedback is an important aspect for many patients who have just undergone medical treatment, may be unsure of their capacity to safely reclaim levels of physical fitness, struggle with corresponding psychosocial issues, and to support their natural healing process. Themes articulated among cancer patients who use integrative modalities include empowerment, camaraderie, and community with those facing similar challenges, pain relief, increased fitness, relief or transferability of anxiety and stress through the use of various techniques learned, enhanced future perspective, and higher levels of motivation to continue improvements in fitness levels and pain reduction (46,157–159).
Of equal importance is the engaged dialog of health care professionals with patients on interventions such as dietary supplements, which may help or harm, particularly during active treatment, and rather stearing patients toward modalities that have demonstrated levels of efficacy, are cost-effective, and with minimal or no side effects.