Complementary Medicine in Cancer: A Panel of East-West, Manipulative Therapies and Herbalism

Complementary Medicine in Cancer: A Panel of East-West, Manipulative Therapies and Herbalism

About the Lecture

When cancer is diagnosed, many patients ask what they can do in addition to conventional treatments offered by their surgeons, medical oncologists and other specialists. They want to add additional therapies that will help to improve their wellness, enhance their immune function and/or help them with the side effects of treatment including aches and pain, sleep disruption, changes in appetite, and fatigue to name a few. What are some of the complementary medicine approaches during or after treatment, but have questions about the benefits, efficacy and safety not to mention how to find a qualified practitioner. In a panel format, Mary Hardy, MD, Medical Director, Simms/Mann—UCLA Center for Integrative Oncology moderates a panel addressing the advantages and cautions of manual therapies (massage and chiropractic), East-West Medicine (acupuncture and Chinese herbs) and nutrition and herbs as complements to cancer care.

Moderator

Mary L. Hardy, MD, former Associate Director of the UCLA Center for Dietary Supplement Research in Botanicals and the founding Medical Director of the Cedars-Sinai Integrative Medicine Program. She has over 20 years in clinical practice integrating the best of western conventional medicine with appropriate complementary therapies for a wide variety of patients, including cancer patients.

Panelists

Ka Kit Hui, MD, FACP, is Professor and Director of the Center for East-West Medicine in the Department of Medicine at the David Geffen School of Medicine at UCLA. The Center has established a model system of comprehensive care with emphasis on health promotion, disease prevention, treatment, and rehabilitation through an integrated practice of East-West medicine. Keith Henry, BS, DC, is Asst Professor and Dept Chair of the Cleveland School of Chiropractic. He received his Doctor of Chiropractic from Cleveland Chiropractic College. Amanda McQuade Crawford, BA, MNIMH, received her BA in Medieval History from Vassar College and a Diploma in Herbal Medicine from England. A member of the National Institute of Medical Herbalists since 1986, she currently is in private practice in Ojai, California. She is the author of The Herbal Menopause Book and Herbal Remedies for Women.

Lecture Summary

This is summary of a lecture presented on August 10, 2010. There are many different approaches to complementary medicine in the arena of cancer care. Some of these approaches come from a philosophical perspective that is all encompassing, while others may be more individualized techniques. Here we present three approaches which view similar symptoms from very different perspectives and offer different and complementary approaches for maintaining wellness. Integrative East West Medicine Approach to Patients Traditional Chinese Medicine (TCM) presents a new and different philosophy of life and approach to health and disease. It is often used for a variety of cancer-related issues such as improvement of quality of life, symptom management, improving ability to tolerate conventional therapies, prevention of progression and maintenance of remission. TCM is also used a as prevention for cancer. In the Chinese medical model, all aspects of life are inter-related to one another--nature, social, environment and body- mind. There is a continuous interaction with flow and balance. Mind, body and spirit are never separate. TCM has a different model for understanding cancer as well as all other illnesses. In the TCM model pathogenic factors include external noxious stimuli, such as chemicals and the weather, psychological and emotional factors, lifestyle (e.g., nutritional imbalances) and deficiency and dysfunction of organ network, Qi and blood. There is a constant process in which the body must balance the noxious stimuli and endogenous resistance. Any factor, no matter how seemingly indirect, that increases the amount of noxious stimuli and/or decreases the body's natural resistance can accelerate the cancerous process in the TCM model. . The TCM model sees the local growth of cancer as a manifestation of a larger problem; it is a systemic disease and, therefore, the patient needs to take a systemic approach in treatment. The therapeutic goals for TCM are to restore the normal balance and flow including emotional, fluid, neurotransmitters and blood flow. It is a very individualized approach. It focuses on enhancing the body's endogenous resistance to disease. There is less emphasis on specific causal factors. By doing this the body is able to build up its own resistance; by controlling symptoms it allows the body to heal itself. TCM therapeutic modalities include acupuncture and its variants, such as acupressure and massage of specific points. Herbal combinations individualized to the person are also a significant part of TCM. Tai Chi and Qi Gong and movement modalities which meld mind and body to help the body to heal itself and restore energy flow. TCM also includes health cultivating lifestyles and practices such as diet and sexual functioning. TCM is not used instead of traditional Western medicine for cancer, but rather as an adjunctive therapy. It is believed that by combining these two different philosophies and treatment approaches patients are likely to have the greatest benefits. Neither lens is sufficient to address all aspects of the spectrum of health. An integrative East-West approach has many goals. The first step is to educate the patient about the importance of balance and how the lack of it leads to depletion. The East-West model incorporates life style modifications, such as learning about appropriate types of exercise, nutritional advice and sleep management. Patients are taught self-massage techniques, sometimes on specific acupressure points, to help relieve symptoms and pain. Acupuncture and acupressure are used along with trigger point injections--a Western version of acupuncture. Herbal medicines may be used, but the diet approach is used first. Sometimes patients need their medication routine adjusted to improve their well-being. Finally, one of the most important aspects of this East-West approach is stress management with many different modalities available to achieve stress reduction. Some of you may be surprised to know that in the integrative TCM model, crying is seen as a good thing which helps create an appropriate emotional flow. Acupuncture is a method of sending a signal to the body by using a needle or other means of stimulation, to help the body turn on its own self-healing capacity. There are different ways to stimulate acupuncture points. It has been documented as useful for symptoms such as nausea, vomiting, dry mouth, chronic pain and myofascial pain symptoms. Systematic reviews show acupuncture to be helpful for several specific non-cancer pain conditions. There are only a small number of trials for cancer-specific pain, but the results are promising. Although complementary and alternative treatments are widely used by patients with cancer, the usage of acupuncture is relatively low with rates ranging from 1.7% to 31% depending on the study. Some of the barriers to acupuncture may be the small number of referrals from oncologist and the need to pay out of one's own pocket for the services. Tai Chi and Qi Gong have specific movements that move Qi (energy) in the body. These have many benefits including stress reduction, enhancing oxygen consumption, enhancing muscle strength, increasing flexibility, improving balance, lowering percentage of body fat, reducing mood disturbance, enhancing immunity and improving cardiovascular function. Chinese herbal medicine is of plant, animal and mineral origin. It has been used for many years to treat patients and should be used under the guidance of a well-trained practitioner who knows and understands the theory of Traditional Chinese Medicine. It requires appropriate diagnosis within the TCM model. It is important that these modalities be properly integrated with Western medicine approaches for optimal cancer care. It is not just a matter of picking and choosing techniques, but applying the philosophy and art of TCM. "All forms of medicine aim to ease human suffering and improve quality of life; they differ only in their approaches to the realization of this goal. The blending of Eastern and Western approaches to health and healing can maximize the safety and effectiveness of care in an accessible and affordable manner." The Center for East-West Medicine at UCLA can be contacted at 310 998-9118, cewm@mednet.ucla.edu or through the web at http://www.cewm.med.ucla.edu. Chiropractic Manipulative Therapy Chiropractics focus on the relationship between the body's structure – mainly the spine – and the body's function. Doctors of chiropractic use manipulation (or adjustment) as their primary modality. Chiropractic is used most often to treat musculoskeletal conditions such as problems with the muscles, joints, bones, and connective tissue including cartilage, ligaments and tendons. There are approximately 60,000 chiropractors in the United States; 15,000 of them practice in California. There are currently 15,000 chiropractic students in 18 schools in the US. There are new schools opening and the use of chiropractics is spreading rapidly abroad. Chiropractors go through rigorous educations programs of approximately 4,400 hours, similar in scope to medical education, at an accredited school. They must have completed at least 3 years of college to enter a training program; while many chiropractors have bachelor's degrees, some do not. The programs cover basic sciences and diagnosis for the first two years. The primary therapeutic intervention is manipulation and multiple techniques are taught. Chiropractors can be licensed in all 50 states and many foreign countries and they take a four part national board exam. The scope of practice of chiropractors depends upon the state. For example, in some states, such as Oregon, chiropractors can deliver babies and suture wounds. In Washington, they can only make adjustments to the spine. California has a fairly broad scope of practice, but does not include delivering babies. They are considered primary care physicians and they can (and must) diagnose and refer when indicated. They perform manipulation to treat spinal dysfunction and they can do physiotherapy which includes modalities like heat packs and electrical stimulation. Manipulation is used to restore proper movements to joints. There are many different techniques, but they fall into two general categories, high velocity low amplitude (HVLA) and low force. HVLA has over 300 named techniques, but there are about 10 core techniques. One low force technique called Activator uses a small spring loaded device to create the manipulation. Chiropractors also do myofascial work (reducing discomfort in tight muscles), physiotherapy, exercise recommendations, strength training, and teach balance and posture utilizing their expertise in analyzing gait. Chiropractors may also offer nutrition and supplement advice which is generally good for basic nutritional information. There are courses offered on nutrition and the debate in the field about the role in supplements. It is estimated that 4.8% to 8% of the US population uses chiropractors and that there are approximately 18,000,000 patients per year. Individuals undergoing cancer care may benefit from chiropractic services. Many patients decrease their normal activity and lose movement over the course of their treatment. This can lead to increases in spinal and/or joint pain as well as soft tissue adhesions and contractures (shortening of muscles due to spasm); these can be relieved by the techniques used by chiropractors. Gait and balance can become disrupted and these are additional indications for chiropractic support in the rehabilitation and comfort care of patients with cancer. Being able to seek this type of care can provide a source of control and management in an otherwise very difficult experience. There are some situations where chiropractic techniques are contraindicated (should not be used). For example, individuals with osteoporosis or weak bones should not use chiropractics although some of the low force techniques may be okay. Patient with bone metastases should also avoid chiropractic techniques that use force. Chiropractic is not a cure for any disease including cancer and should not be used instead of a primary care doctor or an oncologist for treatment of other disease and cancer. Chiropractors should also be willing to coordinate care with your regular physician. Any recommendations for vitamins and herbs related to your cancer care should be coordinated with your oncologist to avoid any problems with medications or treatments you are receiving. Massage therapy is also something that may be beneficial. According to the American Cancer Society (ACS) massage is "thought almost universally to be beneficial." Massage cannot cure cancer but it has been shown in several studies to improve quality of life and well-being. Massage decreases inflammation and swelling, improves circulation, and helps with muscle spasms. It also helps individuals with cancer to relax. It causes the release of chemicals in the body that help with pain and provides a distracting experience that helps take one's mind off pain. There is no state license for massage therapy; rather there are licenses issued by each municipality but they do not verify the individual's competence. State certification can be used in any municipality. Typically massage therapists complete certificate programs of 250 or 500 hours of training. There are many advanced techniques and training that are available, especially here in California. If you have cancer you should consider that massage not be done over or near IV's, catheters, or surgical wounds. Massage should not be done over known cancer sites, radiation burns or known tumor sites. Massage over areas where cancer has invaded the bones are also of concern. Circulatory ailments such as phlebitis or varicose veins should also avoid massage. Aggressive styles of massage are also not indicated for people with cancer. There is no evidence to support the myth that massage will spread cancer. When having a massage, it is important to speak to your medical doctor and obtain clearance for this type of therapy. Manual Lymphatic Drainage (MLD) massage is very different than other types of massage. This must be done by a trained MLD therapist and it is used to treat a condition called lymphedema --accumulation of lymphatic fluid in the tissues which often causes swelling, most often in the arm(s) and or leg(s). Lymphedema can develop when lymphatic vessels are missing or impaired, when lymph vessels are damaged or lymph nodes are removed. Radiation therapy and surgery often create the potential for lymphedema. MLD can include a special kind of massage and it is imperative to find someone who is trained and has experience working with people with cancer. MLD should be coordinated with your care from your medical doctor. Modern Herbal Medicine Many herbs can interfere with cancer therapies so it is essential that patients seek out information from knowledgeable practitioners who understand both the cancer treatment and the various herbal treatments. It is important to note that there is no one prescription for all people and that the best approach is one that is tailored to the needs of the individual. The herbs described here are generally ones that do not interfere with chemotherapeutic regimens. However, developing an individualized approach is always the best plan. It is as important to obtain high quality products from known manufacturers as it is to have a skilled professional help you make selections. It is also important to prioritize what things to take. More is not always better; the body cannot handle too many supplements. Patients also need to be monitored for the unexpected when taking supplements. Always disclose your supplement regimen to your primary care doctors. HERBAL PREPARATIONS Selecting safe herbal preparations is not always easy. They come in many different forms. It is not recommended to go online for cancer herbs. If using retail or wholesale formulas patients must find manufacturers that are ethically responsible and self-police their products. Remember, herbal supplementation can also come in the form of food. For example, garlic, ginger and soy are foods that can be eaten that have beneficial qualities. Garlic is simple to use, can be added to food and has a beneficial impact on the immune system and the flora in the colon. Teas are another way to prepare herbs. Green tea and nettle leaf can be steeped or simmered and have good health qualities. Good quality green tea is pale and should not be astringent. Sometimes a weaker tea may be better. Teas have been helpful in preventing recurrent cancers but a green tea pill is not the same as having the tea. Tinctures are concentrated forms of an herb made with water, alcohol and glycerin as well as the herb. Standardized extracts are another method of herbal preparation and include milk thistle, turmeric and grape seed. Sometime herbal preparations, such as reishi mushrooms, are powdered. Capsules and gel-caps are another form for ingesting herbal preparation and can include non-herbal things such as Omega- 3 fatty acids. Finally, topical compresses--made from herbs such as chamomile, cucumber, aloe vera and lavender--may be useful for irritation, burns and wounds. Chamomile tea is good on burns and wounds, cucumber has a cooling effect and is an anti-inflammatory. Aloe vera gel is good for burns and skin irritation. Lavender is safe for most skin and it has some aromatherapy benefits. PROTECTIVE FOODS AND HERBS Organic versions of food may be more protective or at least there is some evidence in the laboratory that organic foods and herbs are more protective against breast cancer cell lines. Below is a list of some foods or supplements that have beneficial effects, some of which have demonstrated protective effects in the cell lines in vitro (in the test tube). It is generally recommended that foods are used first before supplements. Adding a variety of foods to your diet can be the best prevention and protective model.

• Carrots, yams, squash and turnips are high in carotenoids which have anti-cancer and anti-inflammatory benefits.
• Foods rich in vitamins A, E, C folic acid and flavonoids as well as fiber are also protective.
• The cabbage family, which includes foods such as brussel sprouts, cauliflower, and broccoli, has anti-oxidant effects. They can be steamed or added to soups and are easier to digest if less raw. Broccoli triggers glutathione S-transferase and may block carcinogens from damaging cellular DNA.
• Grapes, figs, strawberries, berries and red wine have ellagic acid and it scavenges carcinogens.
• Grape seed extract contains resveratrol which is also found in red wine as well as other plants and foods (mulberries, peanuts). Resveratrol has anti-cancer properties. Grape seed extract seems to strengthen and protect blood vessels, support the immune system, may have cardiovascular benefits and is also an antioxidant that scavenges free radicals.
• Peas and beans have phytosterols which may slow the reproduction of cells in the large bowel to reduce colon cancer risk. Soy and legumes with protein, such as green beans and split peas, are protease inhibitors which reduce enzymes in cancer cells.
• Isoflavone metabolites such as genistein, found in red clover, may block entry of estrogens to cells and genistein may have antiangiogenesis effects.
• Real traditionally made sourdough rye bread, linseed/flaxseeds and sesame seeds have lignans and may have beneficial effects for hormone receptor types of cancers. Sesame seeds also have calcium. Flax oil is a rich source of cancer-preventative and hormone balancing lignans.
• Olive oil has squalene which has protective effects against breast cancer.
• Omega-3 fatty acids which are found in cold water wild caught fish (not the farm raised salmon and trout) may suppress growth of breast tumor cells and have anti-inflammatory benefit.
• Turmeric has curcumin which has anti-oxidant effects. Just a little goes a long way and so adding 200-400 milligrams per day to your diet is a good idea.
• Ginger has a number of benefits. Gingerol is the main pungent constituent of ginger and it has anti-emetic (anti-nausea) properties, improves appetite, is an anti-inflammatory and has antioxidant qualities. A crossover study with 48 gynecologic patients who received cisplatin chemotherapy also received ginger in comparison to conventional antiemetic therapies. After the first day, ginger had as many positive effects as the anti-emetic drugs with fewer side effects.
• Garlic is also a powerful antimicrobial agent. It strengthens the immune system, helps lower blood pressure, normalizes blood lipid profiles and inhibits platelet aggregation. It is an antioxidant, antifungal, anti-carcinogenic and anti-inflammatory agent.
• Turmeric, ginger, garlic and the onion family all help the liver to filter out toxins. These may be especially helpful while getting chemotherapy.
• Echinacea appears to have anti-inflammatory effects and may also contribute to an immune modulation.
• Black cohosh has anti-estrogenic effects on human breast cancer cells. It is also an antispasmodic. Studies of postmenopausal women who had high intake of phytoestrogens corroborate earlier suggestions that phytoestrogens (Black Cohosh) improve heart health. With regard to hot flashes, different studies have shown different effects; however, the longer study (lasting one year) of 136 women with breast cancer survivors on tamoxifen showed a reduction in hot flashes and a reduction in severity of hot flashes in the group that took a specific black cohosh. There was no evidence of adverse events.
• Green tea, as noted above, has some health benefits. For cancer prevention it is generally recommended that 5-10 three ounce size cups are consumed daily. For patients with cancer, 10 cups per day may be more appropriate. Systematic reviews of case control studies and cohort studies show lower incidence and recurrence with highest use of green tea. There is no consistent dose response relationships, no control for preparation of the tea and no clinical trials. There may be some genetic factors that play a role in the positive effects associated with green tea.
• Milk Thistle contains lignans and there is some evidence to suggest that it has protective and antioxidant qualities for liver cell membranes. It may also inhibit breast cancer and prostate cancer based on some in vitro studies. It is also a mild diuretic.
• Rosemary and sage contain phenolic diterpene and are strong antioxidants. This may be good to add to the diet on non-chemotherapy days. They also have anti-inflammatory properties

It is important to remember that these foods are not the "big guns" against cancer‒that is what Western medicine has to offer. However, diet can be a powerful adjunctive tool. By eating a diet that is rich in these many different foods and herbs, there may be combined benefits that lead the body to being more cancer unfriendly which in turn may be helpful in both prevention of cancer and prevention of cancer recurrence. Summary There is no magic bullet to prevent cancer or prevent recurrence; however, there are activities in which an individual can engage to reduce the likelihood of recurrence or boost the body's natural healing abilities. These approaches can come from many different sources and while the research to date may be limited on many of these, there is a growing interest in understanding the complex relationship between these different approaches in their anti-cancer value and their ability to improve quality of life. Not all approaches will be compatible for all people; however, with guidance individuals may find some activities that help them to feel strong, live a more comfortable life and hopefully maintain wellness. Editor's Note: Choosing integrative approaches requires knowledge of both clinical and evidence-based literature. Becoming educated from reliable sources is a must. The Simms/Mann – UCLA Center for Integrative Oncology can assist patients in making decisions about their complementary and integrative choices. Our Integrative Oncology Specialists offer individual integrative assessments tailored to the needs of the individual, taking into consideration a wide range of important factors. As part of the session, a Body Mass Index analysis is done. These services are fee-for-service. In addition, dietary supplements selected by our Integrative Oncology Specialists, with attention to safety and quality, are available at Reflections Boutique, 200 UCLA Medical Plaza, Suite 163 and online. For information and enrollment call 310-794-6644. The supplements are also available online. For reprint authorization, contact SimmsMannCenter@mednet.ucla.edu.