An Integrative Path to Wellness
The spring 2009 issue of Lymphoma Today, the Lymphoma Research Foundation's (LRF) newsletter, contained portions of this article by Jo Cavallo. The full article, including additional resources, what you should know before getting a massage and taking another look at Vitamin C and cancer are found below.
Introduction
The Role of Integrative Medicine in Lymphoma
Caution: Not Everything That Is Natural Is Good for You
The Importance of a Healthy Diet and Exercise
The Bottom Line
Where to Find Help
What You Should Know Before Getting a Massage
Taking Another Look at Vitamin C and Cancer
Introduction
Although the practice of using a holistic approach to treat disease, relieve symptoms and promote healing dates back to the fourth century, B.C., when the Greek physician Hippocrates first advocated natural remedies to combat illnesses, holistic medicine really came into vogue in the 1960s and '70s. The concept of holistic medicine is rooted in the belief that when one part of the body or mind is not functioning properly, the health of the whole person is affected and, therefore, therapies that treat the mind, body and spirit are necessary to make the person well.
Over the years, holistic medicine has morphed into two general categories: alternative and complementary, commonly identified by the acronym CAM (complementary and alternative medicine). However, medical experts say the term is problematic for cancer patients because, while there are distinct differences between the categories, patients often confuse the two approaches. Alternative therapy refers to unproven or disproven treatments that are used in place of standard or proven therapy, and complementary therapy is used in conjunction with standard medicine to help improve a patient’s quality of life and relieve chemotherapy and radiation side effects.
"The term CAM is an obstacle for my colleagues and for the public because people think of alternative medicine, they don't hear the word complementary. Alternative means instead of conventional therapy and we’re not talking about that. We're talking about using the best evidenced-based complimentary therapies alongside conventional-based therapies to improve quality of life and the effects of chemotherapy and lessen the side effects of cancer therapies and the disease," says David Rosenthal, MD, past president of the Society for Integrative Oncology and medical director of the Leonard P. Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute in Boston.
"When you're talking about cancers, there are no viable alternative treatments," says Kathleen Wesa, MD, assistant attending physician in the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center in New York City. Rather than CAM, oncologists prefer the term “integrative medicine," which they say more accurately describes therapies that complement conventional cancer treatments. "The term integrative medicine is becoming more popular and we're hoping that it’s looked on more sincerely and not looked upon as alternative medicine," says Dr. Rosenthal.
Integrative medicine combines traditional cancer care with a vast array of unconventional therapies, including biologically-based products like herbs, botanicals and vitamins; special diets; chiropractic care, acupuncture and massage; mind/body relaxation techniques such as Reiki, yoga, meditation and guided imagery; and health-related prayer to alleviate treatment side effects and, in some cases, to even improve disease outcome.
The Role of Integrative Medicine in Lymphoma
While the use of unorthodox remedies to treat illness has a long history in this country, it was not until 1992 when the National Institutes of Health launched the Office of Alternative Medicine, now called the National Center for Complementary and Alternative Medicine (NCCAM), that the study of alternative and complementary therapy gained real legitimacy in traditional medicine. Since 1999, NCCAM has funded more than 2,200 research grants, including 370 that involved the treatment of cancer. Besides NCCAM, many major academic cancer centers, including Memorial Sloan-Kettering, Dana-Farber, MD Anderson Cancer Center and the Mayo Clinic, have also launched clinical studies in complementary therapies. And some are showing benefits in the treatment of lymphoma patients.
"I think that the role of integrative oncology in lymphoma patients is to help them with disease symptoms and with the treatment of the cancer, but not to cure the lymphoma," says Donald Abrams, MD, chief of hematology/oncology at San Francisco General Hospital and director of Integrative Oncology Research at the University of California, San Francisco Osher Center for Integrative Medicine.
In fact, complementary therapies are proving to be so beneficial in relieving the treatment side effects of patients suffering from various blood cancers, Dr. Rosenthal says that the number of physician referrals to integrative medicine specialists he sees is second only to those for patients combating breast cancer.
"What many lymphoma and leukemia patients are looking for is relief from symptoms and improving their quality of life and outcome of the disease. We know that some treatments for cancer cause nausea and vomiting and we know that acupuncture reduces nausea and vomiting and the need for [antiemetic drugs like] Ondansetron (Zofran), which can also cause side effects," says Dr. Rosenthal.
There is also evidence that body-based practices such as massage therapy can be instrumental in reducing pain and producing a sense of well-being in cancer patients. "We know that patients' pain scores as well as other symptoms such as anxiety, depression, insomnia and fatigue were decreased by 50 percent following a massage and that relief lasted for 48 hours," says Dr. Wesa. "There are also many calming effects from massage therapy such as an increase in the sense of serenity." However, Dr. Wesa cautions, before lymphoma patients decide to get a massage they should check with their oncologist to make sure their blood counts are normal and that they do not have lymphedema, localized fluid retention caused by a compromised lymphatic system, and that they go to a qualified massage therapist. (See "What You Should Know Before Getting a Massage")
Caution: Not Everything That Is Natural Is Good for You
While some complementary therapies like meditation, acupuncture and therapeutic massage have been found to be safe and effective in providing symptom relief from cancer treatment, others, such as the use of botanicals, herbs, vitamins and antioxidants, may actually be harmful, rendering some chemotherapy agents and radiation therapy less effective and more toxic. At the forefront of the controversy is the high-dose use of over-the-counter antioxidant supplements like vitamins A, C and E. Even antioxidant-rich drinks like green tea and pomegranate juice have come under scrutiny.
"Many chemotherapies like the alkylating agents cyclophosphamide (Cytoxan) and nitrogen mustard act by interfering with the oxidative process around the cells and there is some literature to suggest that if you give antioxidants you’re preventing that oxidative process, so you're interfering with the overall aspects of radiation and chemotherapy," says Dr. Rosenthal.
Until more definitive research is done, say experts, it is best for lymphoma patients to avoid using antioxidants and dietary supplements, even in low doses. "Antioxidants are probably acceptable for people who don't have cancer because they help protect the cells. But if you have cancer and you’re undergoing chemotherapy, are you protecting the cancer cells as well? You don't want to be drinking juices that are high in antioxidants such as cranberry, pomegranate, acai, goji or mangosteen because they have the potential to interfere with chemotherapy or radiation therapy. Having one cup of green tea per day is probably okay, but we don't know that for sure," says Dr. Wesa. "It is safest to avoid consuming large quantities of high-antioxidant containing foods and beverages during chemotherapy and/or radiation therapy. The antioxidant dietary supplements are definitely contraindicated."
One area of complementary medicine that is getting a lot of study is the efficacy, safety and toxicity of combining botanicals and herbs with conventional chemotherapy. "I don't think we know as integrative oncologists the extent to which certain things interact," says Dr. Abrams. "We have researchers at the National Cancer Institute (NCI) that do very elegant pharmacokinetic interaction studies between botanicals and chemotherapeutic substances and report seeing changes in the concentration of the chemotherapy when taken in the presence of a botanical. For example, I don't think a patient getting chemotherapy should be taking St. John's wort because it seems to decrease the area under the curve for most chemotherapeutic agents that are metabolized by the same liver enzyme system, [making the treatment less effective]."
The Importance of a Healthy Diet and Exercise
Although taking over-the-counter dietary supplements should be avoided during lymphoma treatment, eating a nutrient-rich diet is essential to maintaining stamina, boosting immune function and reducing the side effects of treatment. "If you have a malignancy that involves your immune system, down ramping inflammation in the body is desirable. And there are nutritional approaches for non-Hodgkin lymphoma patients that can be done both for the impact of inflammation on angiogenesis (the growth of new blood vessels), apoptosis (cell death) differentiation and immune competence," says Dr. Abrams. "You can minimize inflammation by eating an anti-inflammatory diet high in Omega 3 fatty acids and limiting the intake of animal-source fats to avoid Omega 6 fatty acids, which are pro-inflammatory."
Experts also recommend following the USDA Food Guide Pyramid (mypyramid.gov) to maintain a healthy diet while undergoing cancer therapy, including eating plenty of fruits and vegetables - at least two to four servings of fruits and three to five servings of vegetables a day - whole grains and chicken. Maintaining a regular exercise program most days of the week is also recommended to help reduce fatigue and stress and build muscular strength. However, before starting or resuming any exercise program, talk with your doctor to see how much and what types of activity are most appropriate for you.
The Bottom Line
The good news for lymphoma patients is that many lymphomas are treatable and curable with conventional medical care and patients should never consider alternative medicine alone for treatment, despite the "natural" cancer cure claims found on the Internet and elsewhere.
If you are interested in developing an integrative treatment plan, talk to your healthcare team about what might work best for you based on medical evidence and experience. And be sure to tell your medical team about any dietary supplements and vitamins you are taking and ask about potential conflicts or interference with your treatment.
"Doctors should ask their patients about their use of complementary therapies," says Dr. Abrams. "But if patients are not asked, they should tell their providers what they’re taking."
Where to Find Help
To learn more about integrative medicine and the research that is being done, visit these websites.
What You Should Know Before Getting a Massage
Anyone who has had a massage can testify to its relaxing and rejuvenating benefits. And for lymphoma patients undergoing treatment, having a therapeutic massage can be especially helpful in relieving pain, fatigue and anxiety. However, experts caution that there are some inherent risks in getting a massage that patients should know about before having one done.
"For lymphoma patients, the massage has to be performed by someone who is familiar with working with cancer patients," says Kathleen Wesa, MD, assistant attending physician in the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center. "You can't go to any massage therapist. There are some considerations, for example, if someone's blood counts are low, if the patient has had surgery or lymphodema. You don’t want to be doing deep tissue massage on someone who has low platelets or on someone who is frail."
Because the needs of cancer patients and survivors are so unique, some spa facilities are now offering services specifically designed for them. Although, once again, some precautions should be taken to ensure that the facility and therapist are qualified to treat cancer patients.
"When a patient contacts a spa facility, she should always ask what type of specialized training the therapists have," says Barbara Stirewalt, director of The Spa at Mohonk Mountain House in New Paltz, New York, which began offering spa services to cancer patients two years ago. "If the spa facility doesn't offer clients a health questionnaire to fill out before getting a massage, clients should inform the spa about their treatment status. It’s especially important to know whether lymph nodes have been removed. In addition, clients should ask questions about the therapists' qualifications in treating cancer patients or survivors."
Another important consideration, says Stirewalt, is to be sure that the massage therapist has received advanced training, preferably endorsed by the National Certification Board for Therapeutic Massage and Bodywork or by the American Massage Board Association.
To ensure your safety, check with your medical team before getting a massage and ask what you should be aware of regarding any potential complications or restrictions from your treatment.
Taking Another Look at Vitamin C and Cancer
Thirty years ago, Nobel laureate Linus Pauling made headlines with the publication of his book Cancer and Vitamin C, which suggested that vitamin C supplements could lengthen survival times of terminally ill cancer patients. Although Pauling's findings were later contested, new research on vitamin C and it is anti-tumor effect on non-Hodgkin lymphoma and other cancers may vindicate Pauling's earlier work.
A phase II clinical trial using intravenous high-dose vitamin C for patients with refractory non-Hodgkin lymphoma was recently launched at the Jefferson-Myrna Brind Center of Integrated Medicine at the Thomas Jefferson University and Hospital in Philadelphia to determine whether the treatment can slow the disease from progressing after first-line treatment has failed.
"We decided to do the study based upon the positive laboratory data in mice models as well as anecdotal data in human studies showing that high-dose vitamin C can be helpful for certain cancer types," says Daniel Monti, MD, executive and medical director of the Myrna Brind Center and lead investigator of the trial. "The reason that it's helpful is because we’re giving it in doses you can only take intravenously. It does not work orally. Taken intravenously, vitamin C diffuses into the extra cellular space outside the blood stream and a conversion to hydrogen peroxide takes place, which causes apoptosis, or cell death, in certain types of cancers."
Preliminary data is showing that one of those cancer types is non-Hodgkin lymphoma because, says Dr. Monti, NHL cells do not process hydrogen peroxide. A phase I study of intravenous high-dose vitamin C in patients with various types of cancer has already been completed and showed that the treatment is safe and nontoxic. "We're starting with refractory non-Hodgkin lymphoma patients because we want them to get first-line care that's been proven to help. For patients who are no longer responding to first-line care or who never responded to it, this is worth a try because it's not going to hurt them," says Dr. Monti.
Despite Dr. Monti's early findings, the controversy surrounding vitamin C and its potential cancer benefits has not subsided. A recent laboratory study by researchers at Memorial Sloan-Kettering Cancer Center of the effects of vitamin C on cancer cells found that the supplement reduced the effectiveness of chemotherapy drugs. In another set of experiments in which mice were implanted with cancer cells, the researchers found that the tumors in mice implanted with cancer cells pretreated with vitamin C grew more quickly than tumors in mice not pretreated with vitamin C. However, says Dr. Monti, "in this study dihydro ascorbic acid, a form of vitamin C that is toxic to humans, was used making the generalization of the results difficult to interpret."
While Dr. Monti's FDA-approved study is using vitamin C in large intravenous dosages that function like a drug, until more is known about the role vitamin C and other antioxidants have on cancer and cancer treatment, your best bet is to stick to a healthy diet to get the nutrients you need rather than rely on dietary supplements. "Vitamin E, C and beta carotene are ones that people get over the counter, but you can get all those nutrients in the pulp of a glass of orange juice. So it behooves us to be very careful until we have seen what's going on [with the research]," says David Rosenthal, MD, medical director of the Leonard P. Zakim Center for Integrative Medicine Therapies at Dana-Farber Cancer Institute.
