Breast cancer is a "survivable disease" for most women.1 The relative survival rates are 89% at 5 years, 82% at 10 years, and 77% at 15 years.2 Most are for postmenopausal women whose tumors are node-negative, estrogen-receptor positive (ER+), and HER2/neu-negative.3-6 After cancer patients have survived 5 years, they are thought to be cancer free. However, breast cancer is a late-recurring disease. Twenty percent of women who were disease-free 5 years posttreatment are still at risk of a recurrence at 10 years.7 Most of the late-recurring cases had estrogen-receptor positive tumors and their oral hormone-modifying medication tenure is only 5 years. This leaves a significant gap in the conventional treatment of breast cancer.
After conventional cancer treatment removes the manifestation of the body's underlying state of imbalance, the process of facilitating healing begins, in order to help restore health and hopefully remain cancer free. I propose that naturopathic medicine can play a role in reducing this late recurrence risk by treating patients with basic complementary and individually designed, constitutional methods. I review the roles that naturopathic physicians play in helping breast cancer survivors to heal.
Naturopathic Care After Conventional Treatment for Breast Cancer
To summarize the roles that naturopathic physicians play in support of those healing after breast cancer treatment, I describe three broad categories: complementary care, basic naturopathic care, and individualized constitutional care (Table 1).
Supporting breast cancer patients recovering from surgery, chemotherapy and/or radiation is the first of role that we play after treatment ends. Next, manage lingering treatment-related side effects and potential toxicities. This is reviewed with Dr. Kelly Jennings in our textbook, The Breast Cancer Companion: A Complementary Care Manual.8
Next, support patients taking hormone-modifying medications. We have many tools for limiting symptoms related to menopause, arthralgia, myalgia, and so on.9 Help monitor them for endometrial, osteoporotic, hepatic, clotting, lipid changes, and other possible signs of toxicity.10 Help patients avoid taking contraindicated supplements and botanicals. In addition, offer agents found to be synergistic with selective estrogen-receptor modulator (SERM) and aromatase inhibitor (AI) medications. See Table 2 for a summary of contraindications and synergistic agents.
Basic Naturopathic Care
In addition to complementary care during conventional treatment, naturopathic physicians offer numerous methods for helping patients afterwards. What I am calling basic naturopathic care is a post-treatment naturopathic template.
First, educate patients on the evidence-based lifestyle modifications found to help prevent recurrence by up to 50%. Previously, we relied on primary prevention studies. Now we have a small body of data that can be used to empower patients to optimize their lifestyle in order to reduce risk of recurrence. Conflicting dietary intervention trials prove confusing. Some studies do, however, support recommending a diet that is high in fiber, vegetables, fruit, and soy and calories from fat as low as 15%. See Table 3, for details and references. There seems to be consensus, however, about the therapeutic value of exercise, achieving optimal body mass index, limiting alcohol intake and drinking green tea. Studies on preventing recurrence with an empowering lifestyle are detailed in Table 3.
Many nutritional supplements and botanicals recommended in breast cancer treatment plans are based on primary prevention studies and warrant consideration such as turmeric, mushroom extracts, melatonin, higher dosages of CoQ10. These agents are more thoroughly reviewed and are referenced in The Breast Cancer Companion as well as The Definitive Guide to Cancer.11,12
There are several agents, however, that have prevention of recurrence data in animals and humans. Taking vitamin supplements, vitamin C and E, CoQ10 with antioxidants, drinking green tea all have inverse associations with breast cancer recurrence. Taking Coriolus versicolor mushroom extracts, melatonin, and black cohosh were also found to increase survivorship among specific subsets of breast cancer survivors. See Table 4 for studies, references, and an associated basic treatment plan.
In review, there are important roles that the naturopathic physicians offer patients after conventional breast cancer treatment. The aim of complementary care is to assist patients in recovery and healing after conventional oncologic therapies and to resolve residual side effects. In addition, basic naturopathic guidelines provide a template for helping patients to reduce recurrence risk with both lifestyle medications and evidence-based natural therapeutics.
Individualized, Constitutional Treatment of People Who Have Had Breast Cancer
Conventional approaches to treating breast cancer are like the Coast Guard arresting a speedboat. This is especially important in cases of aggressive or late-stage disease. Naturopathic approaches are like a sailboat harnessing the natural power of the wind to guide the boat to safety. Adding these approaches is recommended, especially for the majority of women who may develop late-recurring breast cancer. I propose that together, we may be able to arrest the manifestation of this disease and guide the patient toward healing.
Naturopathic foundational principles include treating the whole person, not treating cancer, treating the underlying cause of an illness, not the symptom, using the healing power of nature, and removing obstacles to a cure. To inspire transformational healing, first identify the patient's constitutional factors.
There are nonmodifiable risk factors that many patients share, such as being female and aging.13 However, many patients have no other risk factors like obesity, smoking, DES exposure, excessive alcohol consumption, gene mutations, or family history. Other women who do have breast cancer risk factors never get it.14 The cause in many cases is multifactorial. Consider a combination of factors like genomics, unfortunately timed toxic exposures, individual constitution, and lifestyle factors.
Over the 14 years that I have treated women with breast cancer, I have noted that there are common constitutional factors that need to be treated in order for transformational healing to occur. For simplicity's sake, I have grouped them into three broad categories: detoxification, inflammation, and stress response.
To identify an individual's constitutional imbalance(s), take a thorough medical history, environmental exposure history, psychological/social history, and family history.15 You may include a Chinese Medical history. Perform a traditional and nutritional physical examination, Chinese Medicine pulse, tongue, and energy evaluation if desired. From the clues presented, run appropriate tests. Then methodically treat each layer of dysfunction using naturopathic foundation principles (Table 1).
Detoxification refers to the risk of malignant transformation from breast tissue toxicity in an individual whose genome inhibits metabolism and elimination of toxins.16 Exposure is most concerning at times of rapid cell division such as in utero or during puberty.
To evaluate the hypothesis that detoxification issues play at least a partial role in the etiology of a patient's breast cancer, perform single nucleotide polymorphism (SNP) testing.17,18 Evaluate: (1) hormone metabolism; (2) detoxification of specific environmental toxins; (3) medication metabolism. Consider testing sufficiency of amino acids used in detoxification as well as a urine organic acids test to evaluate hepatic stress.
Subsequent to identifying SNPs related to hormone metabolism, order an estrogen metabolism test of the ratio of 2-hydroxy estrone to 16-alpha hydroxyestrone. Higher ratios are associated with reduced risk of breast cancer, especially in those with ER-negative tumors and if premenopausal.19-21 If patients are taking hormone-modifying medications, consider treating issues of estrogen metabolism with diet alone. Consider a diet low in animal protein, or vegan plus low-toxin fish, ground flaxseed meal (especially in those with catechol-O-methyltransferase polymorphism, or COMT SNP), organic whole soy foods, cruciferous vegetables, and green and white tea.22-26 If they are not on hormone-modifying drugs, consider diindolylmethane (DIM) and test estrogen metabolism quarterly until therapeutic dose is achieved.27
If a patient has SNPs that affect detoxification of solvents or polyaromatic hydrocarbons and their history indicates, consider testing specific toxin load.28 If they are deficient in amino acids of detoxification and/or have hepatic stress, consider replenishing amino acids during a six-week toxin-specific cleanse. Follow with quarterly 10-day cleansing.
If a patient has a null GSTM SNP and history indicates, cautiously consider oral or IV-chelated toxic metal test and treatment. It is theoretically possible that liberating carcinogens may increase vulnerability to mutation.
For some, the constitutional imbalance is related to inflammation. This refers to the risk of malignant cellular transformation of breast tissue resulting from states of systemic, tissue, and/or intracellular inflammation. Research supports the potential role of inflammation as a factor that may contribute to breast cancer occurrence.29 In 2009, the Journal of Clinical Oncology reported "some of the most persuasive evidence yet that chronic inflammation might increase the risk of breast cancer recurrence."30 Further evidence points to a negative immune shift from TH1 to TH2 dominance that contributes.31
When considering treatment for chronic inflammation, look for a thickly coated or scalloped tongue, slippery pulse, edema, overweight. Listen for a history of bloating, diarrhea, constipation, digestive infections, congestion, allergies, discharges, itching, phlegm, rash, pain, and so on. Research studies have identified blood markers of inflammation that have been correlated to breast cancer incidence, recurrence, and prognosis: CRP, circulating acute phase proteins, interleukin 6, VEGF, TH2 immune activation complexes, D-dimer, and so on.32-38
Evaluate and treat thyroid dysfunction. Autoimmune thyroid disorders account, to a large extent, for the increased prevalence of thyroid disorders among breast cancer patients.39
Test for food allergies/intolerances to eliminate food-based inflammation. Consider allergy elimination and an anti-inflammatory diet as a template for food-based treatment of inflammation.40,41
I have observed that digestive infections/dysbiosis are common sources of inflammation in breast cancer patients, especially those who have deficiencies in the Earth element from a Chinese Medicine perspective. Test stool and/or urine organic acids to evaluate and guide treatment of dysbiosis.42 Restore the integrity of the digestive mucosa.
In addition to treating the cause of the inflammation, consider natural anti-inflammatory agents that also inhibit breast cancer such as fish oil, curcumin, and so on.43-45
Cancer is not caused by stress alone.46 The stress response constitutional factor refers to the theory that while the cause of breast cancer is often multifactorial, it may partially result from or progress due to a patient's neurochemical response to chronic stress. There is value in treatments that limit the impact that chronic negative stress response may have on the immune and endocrine systems.
Certain genotypes of the COMT SNP are correlated with breast cancer risk and prognosis.47,48 COMT SNPs result in 3- to 4-fold less COMT enzyme activity and therefore inhibition of catecholamine degradation.49 Prolonged activation of either the sympathetic nervous system or the hypothalamic-pituitary-adrenal axis (stimulator of cortisol production) may promote tumor growth.50 One researcher of ovarian cancer stated that the evidence may be even stronger for stress's playing a role in cancer progression.51 Others found elevations of catecholamines in tumor samples of patients under extreme stress compared with those who were less stressed.52 In addition, cancer patients reporting higher stress levels have elevated levels of tumor angiogenic cytokines.53
Consider testing stress response as a constitutional factor by testing the COMT SNP, neurotransmitters, DHEA, diurnal cortisol, and amino acids as they relate to neurotransmitters (Table 1).
I use a combination of lifestyle, mind-body-spirit treatment, energetic balancing with acupuncture, and qi gong, as well as Western and Chinese botanicals, amino acids, and other nutritional supplements (Table 1). My goal is to support patients in experiencing longer periods of being in the moment. I have a theory: the more time spent being in the moment, the more time spent vibrating at the appropriate frequency for our cellular being. I like to think that this equates with slowing down those rapidly dividing cancer cells.
Individualized, constitutional treatment of people who have had breast cancer requires adherence to the foundational principles of naturopathic medicine. By identifying and treating the cause, treating the whole person, and inspiring the healing power within each patient by removing obstacles to her cure, we facilitate transformational healing. By combining this approach with evidence-based basic naturopathic care and complementary care methods, we are at the very least inspiring health.
Barbara MacDonald, ND, LAc, MSOM, coauthored The Breast Cancer Companion: A Complementary Care Manual, a practitioner's guide to support women through conventional cancer treatment (2010). Dr. MacDonald graduated from National College of Naturopathic Medicine (NCNM) with degrees in naturopathic medicine and Classical Chinese medicine (1997, 2003 respectively). She did women's health with a focus on breast cancer care at A Woman's Time in Portland, Oregon, for 14 years. After her residency, she was adjunct teaching faculty at NCNM, where she started the first dual-degree cancer teaching shift. She returned to New England in 2010. She currently practices at Camden Whole Health in midcoast Maine, where she continues to write and lecture on the subject of breast cancer care. Contact: www.thebreastcancercompanion.com or firstname.lastname@example.org.
1. Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2008 [Web page]. National Cancer Institute. http://seer.cancer.gov/csr/1975_2008. Based on November 2010 SEER data submission, posted to the SEER website 2011.
3. Lyman GH, Kuuderer NM, Lyman SL, et al. Menopausal status and the impact of early recurrence on breast cancer survival [online article]. Moffit Cancer Center & Research Institute. http://www.moffitt.org/moffittapps/ccj/v4n4/article5.html. Accessed December 4, 2011.
4. Gloeckler, LA, Eisner MP. Cancer of the female breast. SEER Survival Monograph.1998-2001;13:101–110. Available at: http://seer.cancer.gov/publications/survival/surv_breast.pdf. Accessed December 4, 2011.
5. Dunnwald, LK, Rossing MA, Li CI. Hormone receptor status, tumor characteristics, and prognosis: a prospective cohort of breast cancer patients. Breast Cancer Res. 2007;9(1).
6. Attiqa N, Mirza MD, Nadeem Q, et al. Prognostic factors in node-negative breast cancer. Ann Surg. 2002;235(1):10–26.
7. Brewster AM, et al. Residual Risk of breast cancer recurrence 5 years after adjuvant therapy. J Natl Cancer Inst. 2008;100;DOI:10.1093/jnci/djn233.
8. MacDonald B, Jennings K. The Breast Cancer Companion: A Complementary Care Manual. Portland, OR: Brains and Braun Publications; 2010:95–192.
9. Ibid.; 200–201, 207–208.
10. Tamoxifen [Web page]. MedlinePlus. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682414.html. Accessed November 27, 2011.
11. MacDonald BM, Jennings K. Breast Cancer Companion. 292–305.
12. Alschuler L, Gazella Karolyn. The Definitive Guide to Cancer. 3rd ed. Berkeley, CA: Celestial Arts; 2010.
13. American Cancer Society. Breast cancer and early detection [online document]. http://www.cancer.org/acs/groups/cid/documents/webcontent/003165-pdf.pdf. Accessed December 4, 2011.
15. Marchese M. Environmental exposure history questionnaire. Permission granted by author. Available at: www.drmarchese.com/images/Exposure_Questionnaire.doc. Accessed December 6, 2011.
16. Marchese M. Environmental links to breast cancer and endometriosis. Naturopath Doctor News Rev. 2011;7(2):9–10.
17. Bugano DD, Conforti-Froes N, Yamaguchi NH, et al. Genetic polymorphisms, the metabolism of estrogens and breast cancer: a review. Eur J Gynaecol Oncol.2008;29(4):313–20.
18. Consider the Genova Diagnostics Laboratory DetoxiGenomic Profile. Available at: http://www.gdx.net/product/10038. Accessed December 6, 2011.
19. Muti P, Bradlow HL, Micheli A, et al. Metabolism and risk of breast cancer: a prospective analysis of 2:16 hydroxyestrone ratio and risk of breast cancer in premenopausal and postmenopausal women. Cancer Epidemiol. 2000;11:635–640.
20. Eliassen AH, Missmer SA, Tworoger SS, et al. Circulating 2-hydroxy and 16-alph hydroxyl estrone levels and risk of breast cancer among postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2008;17(8):2029–2035.
21. Muti P, Bradlow HL, Micheli A, et al. Metabolism and risk of breast cancer: a prospective analysis of 2:16 hydroxyestrone ratio and risk of breast cancer in premenopausal and postmenopausal women. Cancer Epidemiol. 2000;11:635–640.
22. Adlercreutz H, Fotsis T, Höckerstedt K, et al. Diet and urinary estrogen profile in premenopausal omnivorous and vegetarian women and in premenopausal women with breast cancer. J Steroid Biochem;1989;34(1–6):527–530.
23. McCann SE, Wactawski-Wende J, Kufel K, et al. Changes in 2-hydroxyestrone and 16alpha-hydroxyestrone metabolism with flaxseed consumption: modification by COMT and CYP1B1 genotype. Cancer Epidemiol Biomarkers Prev. 2007;16(2):256–262.
24. Nettleton JA, Greany KA, Thomas W, et al. The effect of soy consumption on the urinary 2:16-hydroxyestrone ratio in postmenopausal women depends on equol production status but is not influenced by probiotic consumption. Nutr Cancer. 2005;135(3):603–608.
25. Fowke JH, Longcope C, and Hebert JR: Brassica vegetable consumption shifts estrogen metabolism in healthy postmenopausal women. Cancer Epidemiol Biomarkers Prev. 2000;9:773–779.
26. Bradlow HL and Sepkovic D. Diet and Breast Cancer. Ann NY Acad Sci. 2002;963, 247–267.
27. Dalessandri KM, Firestone GL, Ritch MD, et al. Pilot study: effect of 3, 3′-diindolylmethane supplements on urinary hormone metabolites in postmenopausal women with a history of early-stage breast cancer. Nutr Cancer. 50(2):161–167.
28. Consider Metametrix Clinical Laboratory's Toxic Effects Profiles. Available at: http://www.metametrix.com/test-menu/profiles/categorized. Accessed on December 6, 2011.
29. Cole S. Chronic inflammation and breast cancer recurrence. J Clin Oncol. 2009;27(21):3418–3419.
31. DeNardo DG, Coussens LM. Inflammation and breast cancer: balancing immune response: crosstalk between adaptive and innate immune cells during breast cancer progression. Breast Cancer Res. 2007;9:212.
32. Pierce GL, Ballard-Barbash R, Bernstein L, et al. Elevated biomarkers of inflammation are associated with reduced survival among breast cancer patients. J Clin Oncol. 2009;27(21):3437–3444.
33. Han Y, Mao F, Wu Y et al. Prognostic role of C-reactive protein in breast cancer: a systematic review and meta-analysis. Int J Biol Markers. Epub 2011 Dec 2:0:105301/JBM.2011.8872.
34. Cole, op. cit.
35. Bachelot T, Ray-Coquard I, Menetrier-Caux C, et al. Prognostic value of serum levels of interleukin 6 and of serum and plasma levels of vascular endothelial growth factor in hormone-refractory metastatic breast cancer patients. Br J Cancer;2003;88:1721–1726.
37. DeNardo DG, Coussens LM. Inflammation and breast cancer: balancing immune response: crosstalk between adaptive and innate immune cells during breast cancer progression. Breast Cancer Res. 2007;9:212.
38. Dirix LY, Salgado R, Weytjens R, et al. Plasma fibrin D-dimer levels correlate with tumour volume, progression rate and survival in patients with metastatic breast cancer. Br J Cancer. 2002;86(3):389–95.
39. Giani C, Fierabracci P, Bonacci R et al. Relationship between breast cancer and thyroid disease: relevance of autoimmune thyroid disorders in breast malignancy. J Clin Endocrinol Metabl. 1996;81(3):990–4.
40. See Black J. The Anti-Inflammatory Diet and Recipe Book. Alameda, CA; 2006.
41. Consider anti-inflammatory resources such as those at drweil.com. Anti-inflammatory food pyramid chart available at http://www.drweil.com/drw/u/ART02995/Dr-Weil-Anti-Inflammatory-Food-Pyramid.html. Accessed December 6, 2011.
42. Elena M. Health, probiotics, and inflammation. J Clin Gastroenterol. 2008;42:S177–S178.
43. Mandal CC, Ghosh-Choudhury T, Yonda T, et al. Fish oil prevents breast cancer cell metastasis to bone. Biochem Biophys Res Commun. 2010;402(4):602–607.
44. Simopoulos A. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002 Dec;21(6):495–505.
45. Altenburg JD, Bieberich AA, et al. A Synergistic antiproliferation effect of curcumin and docosahexaenoic acid in SK-BR-3 breast cancer cells: unique signaling not explained by the effects of either compound alone. BMC Cancer. 2011 Apr 21;11:149.
46. Nielsen NR, Grønbaek M. Stress and breast cancer: a systematic update on the current knowledge. Nat Clin Pract Oncol. 2006;3(11):612–620.
47. Onay UV, Aaltonen K, Briollais L, et al. Combined effect of CCND1 and COMT polymorphisms and increased breast cancer risk. BMC Cancer. 2008;8:6.
48. Long JR, Cai Q, Shu XO, et al. Genetic polymorphisms in estrogen-metabolizing genes and breast cancer survival. Pharmacogenet Genomics. 2007;(5):331–338.
49. Dauvilliers Y, Neidhart E, Lecendreux M, et al. MAO-A and COMT polymorphisms and gene effects in narcolepsy. Mol Psychiatry. 2001;6(4):369.
50. Ross, K. Mapping pathways from stress to cancer progression. J Natl Cancer Inst. 2008;100(13):914–917.
52. Lee JW, Shahzad MMK, Lin YG, et al. Surgical stress promotes tumor growth in ovarian carcinoma. Clin Cancer Res. 2009;15(8):2695–2701.
53. Lutgendorf SK, Lamkin DM, Jennings NB, et al. Biobehavioral influences on matrix metalloproteinase expression in ovarian carcinoma. Clin Cancer Res. 2008;14(21):6839–6846.