Botanicals & Breast Cancer

It seems to me that many #midwives are impacted personally by breast cancer. I am not sure if its because we tend to become a bit disembodied, taking care of everyone else and neglecting ourselves, or if there is something about the work itself, the stress maybe or lack of sleep, that increases our risk. It seems odd since many of us #breastfeed our littles right into kindergarten.

When I was working in Indiana, three different midwives passed very quickly of breast cancer and I've cared for many women in my practice who either I diagnosed, or they came to me during treatment, or soon after. This is the most common #cancer in our country, and in women, it represents 30% of all cancers. A friend of mine, also a midwife, has just recently completed her radiation treatment for her own breast cancer, so it has been on my mind more recently (and herbs are always on my mind).

The majority of women will undergo conventional treatment, whether surgery, #radiation or chemotherapy, maybe all of those. Some will even have endocrine therapy. Many of these women still seek additional integrative therapies, and botanical medicine is quite often among those chosen to help relieve symptoms associated with treatment, as well as to improve their health and minimizing risk of cancer return.

Herbal medicine can be very complementary to conventional medicine. This can be tricky though because one must understand their #chemotherapy treatment, molecular targeted therapy, their immune therapy and endocrine therapy, to really understand how each botanical might interact or interfere. It's also extremely important to understand the botanical itself and how it might help or hinder anyone with a breast cancer diagnosis. Phytochemicals certainly can interfere with drug metabolism, drug mechanisms of action, and even the efficacy of radiation, potentially making the toxic impact of treatment even more potent. However, botanicals can also be counterproductive, such that dong quai and fenugreek can raise estradiol levels, which may stimulate estrogen receptor-mediated cell growth which would be contraindicated during hormonal treatment with aromatase inhibitors. Herbs that have anti-platelet or anticoagulant effects should be avoided in women with low platelet counts, which is quite common when being treated with chemotherapy.

Part of this work is also knowing where to attain high-quality botanicals in order to avoid the introduction of potential adulterants, contaminants, excessive extraction residues, or other compounds that might potentially expose even more toxin. My hope, of course, is that those with breast cancer who would like to integrate botanical medicine would work with an expert #herbalist, alongside their endocrinologist, but many ladies are diving in themselves because botanical medicine isn't always well understood by their practitioners.

Turmeric

Systemic inflammation underlies many presentations of cancer and even many of the symptoms associated with treatment. Inflammation is the basis for most chronic disease and poor health outcomes. Turmeric, a well known anti-inflammatory has been studied for this purpose, specifically even for breast, colorectal and gastric cancers and at 300mg doses, three times daily, providing 180mg of curcuminoids daily, and the literature has shown turmeric to result in significantly greater improvements in quality of life after just eight weeks compared to placebo (Panahi et al., 2014). Additionally, various biomarkers for systemic inflammation were reduced in the curcumin group, including tumor necrosis factor-alpha (TNF-a), transforming growth factor-beta (TGF-B), high-sensitivity C-reactive protein (hs-CRP), and calcitonin gene-related peptide (CGFP). The liposomal form of curcumin is thought to minimize herb-drug interactions, as compared to turmeric/curcumin products containing piperine (an alkaloid derived from black pepper) (Mach et al., 2010).

Capecitabine, another commonly used chemotherapeutic, is often associated with hand-foot syndrome, as much as half of those enduring treatment. #Turmeric was used in another study in these clients, at 4g twice a day, and it was found to reduce outbreak by 27.5% after just two doses. When repeated twice more, the incidence fell even more, to 34%. The incidence of severe hand-foot mouth was typically about 29% of cases, but after treatment with the turmeric, this too fell to about 10%. This wasn't a huge study, but outcomes were quite significant (Scontre et al., 2018).

Turmeric is a botanical I would offer most clients undergoing chemotherapy.

Curcuminoids have also shown to help with those who suffer dermatitis from radiation therapy (Ryan et al., 2013). One study offered 2g of turmeric containing 95% curcuminoids, three times daily, by mouth for four to seven weeks and in the placebo group, 87.5% suffered skin thinning and oozing as a result of skin damage from radiation. Only 28.6% of those offered the turmeric suffered. However, another study did not find the same results (Wolf et al., 2018).

Valerian

This one smells like stinky feet, just a heads up. I used in to help my laboring clients sleep at times and when I was first learning herbs, I thought this one went bad in my birth bag and threw it out. Now I use #valerian in tincture form to avoid having to smell feet, but it is super effective. Sleep is often disrupted during conventional cancer treatment, particularly chemotherapy. Poor sleep contributes to overall fatigue and reduced quality of life, so it's an important health marker to monitor and support.

Valerian, Valeriana officinalis, root was studied in a randomized-controlled trial with 227 individuals undergoing cancer treatments who had difficulty sleeping. More than 66% had breast cancer and were receiving chemotherapy. They were randomly assigned to receive 450mg of valerian root standardized to 0.8% valerenic acid or placebo, an hour prior to bed, for eight weeks. They were offered standardized tests to evaluate sleep and while there wasn't an overall improvement is sleep, there were several improvements in secondary outcomes, including #fatigue, sleep latency, amount of sleep per night, and drowsiness. This is the low end of dosing, so it may be useful and there aren't any significant interactions with anticancer drugs or data that it raises serum estrogen levels (Kelber et al, 2014).

American Ginseng

Fatigue is a huge aspect of chemotherapy, rightly so. In many respects we don't want to fight this too much, because the body certainly does need rest. However, American ginseng has been shown to downregulate inflammation and modulate cortisol levels in stressed individuals, which is why experts believe this botanical improves feelings of fatigue in those enduring chemotherapy.

American ginseng, Panax quinquefolius, Araliaceae has been associated with significant improvements of fatigue in an eight-week clinical trial, with 364 randomly assigned individuals actively receiving, or having recently completed curative-intent treatment for cancer. They were provided 2g of American ginseng root extract (3% ginsenosides) or placebo, and a subgroup compared those undergoing therapy verses those just having completed therapy. Results were supportive of American ginseng in these individuals.

Studies have not found American ginseng to impact cytochrome P450 enzymes, so drug-herb interactions are not of great concern. Crude root has not been found to have estrogenic properties (King et al., 2006), and there is some evidence that American ginseng may have an inhibitory effect on the growth of breast cancer cells (Duda et al., 1999). Certainly seems to be a great option for supporting those going through chemotherapy who are needing some relief from their fatigue.

Ginger

This one is maybe more widely known, as ginger is often recommended to pregnant mommas who are nauseous. Clinical studies have yielded varying results on chemotherapy-induced nausea (Marx et al., 2013), but I would say I get about half-and-half improvement on my pregnant clients as well. One positive trial was a double-blind, multisite prospective clinical study that included 744 participants with various types of cancer, although nearly three-fourths did have breast cancer (Ryan et al., 2012). They were all receiving chemotherapy and either received placebo ginger, or were given #ginger in three different doses. They would start this dosing three days prior to receiving chemotherapy and then three days afterwards. Interestingly, all groups had reduced nausea over the group given placebo, but the best outcomes were in the two lowest dosed groups, at 0.5g and 1g compared to 1.5g.

Ginger has previously been found to have antithrombotic actions at higher doses, although the majority of studies really haven't demonstrated this even at 3-5g (Marx et al., 2013). Further, there is some caution about ginger's metabolism through cytochrome P2C9 or cytochrome P3A4, but it does have a rapid half-life which would mitigate the risk of herb-drug interactions (Qiu et al., 2015). It seems though, that in light of all the literature, while ginger seems an acceptable option for #nausea with chemotherapy treatment, the lower doses are wise.

Calendula

One of the most common adverse effects of radiation is painful skin irritation. This can be so significant in fact, like a burn, that it can disrupt treatment. Calendula has long been known as a great soother for irritated skin and there are many over-the-counter creams and ointments with calendula so you may be familiar. The data supports this use, even for those receiving postoperative radiation. One study found skin irritation was decreased by 22% and was more effective than trolamine cream (Pommier et al., 2004). However, interestingly, a randomized, double-blinded study evaluated one of my favorite creams by Weleda, with calendula, for women undergoing radiation for breast cancer and did not find it was improved over another aqueous cream (Sharp et al., 2013). This may be brand specific, although many variables could be at play here.

Green Tea

Green tea can also be used to soothe or improve radiation dermatitis. Green tea has a catechin, Epigallocatechin gallate (EGCG), that scavenges and binds free radicals, protecting DNA from radiation-induced damage. This was demonstrated in a clinical trial in women receiving radiation for breast cancer who utilized green tea solution for four weeks, three times each day (Zhu et al., 2016). It not only improved their skin trauma, but also their pain, burning, itching, and skin pulling. Green tea seems like a great option for reducing the severity of radiation therapy. If you don't already have your own favorite recipe, try mixing sufficient green tea standardized extract powder to obtain 350mg EGCG with 1 liter of saline solution. Then spray this onto the skin with a nasal or throat mister.

Mushrooms

A friend from the fungi kingdom, turkey tail mushroom has been studied on women with node-negative, ER-negative, and stage IIA T2N1 breast cancer and they demonstrated increased drug-free survival to placebo. These women were offered a proprietary processed liquid fermentation of the turkey tail mushroom (Corilous vesicolor or Trametes versicolor, Polyporaceae) known as Polysaccharide Krestin (PSK) at 3g per day (Toi et al., 1992). Another randomized trial demonstrated same outcomes, but these women had operable breast cancer with vascular invasion of the tumor and/or of metastatic lymph nodes (Iino et al., 1995).

A pretty impactful meta-analysis with over 2,587 subjects was later done in 2012, that demonstrated when we add the T. Versicolor at 3g daily to conventional treatment for breast cancer that survival rate is improved by 9% over the next five years, which equates to one additional survivor for every eleven patients treated with the mushroom (Eliza et al., 2012). There are no known herb-drub interactions with turkey tail mushrooms either.

Complementary Botanicals & Conventional Therapy

Conventional breast cancer treatments have offered women many desirable outcomes, including, for many, remission. These treatments though, can be difficult to tolerate. When we can offer more integrative approaches such as utilizing #botanicals to address some of the adverse outcomes of therapy, not only are outcomes improved with regards to treatment, but so potentially is the woman's experience, her sense of autonomy, as well as those willing to endure therapy for fear of suffering. Sadly, in the 2018 guideline for use of integrative therapies during and after chemotherapy, the Society of Integrative Oncology, concluded there is no strong evidence to support the sue of ingested dietary supplements, including herbs, in the management of treatment-related toxicities. More studies and a better understanding is certainly necessary, but when did lack of strong #evidence ever stop conventional medicine from utilizing approaches that for all intents purposes believed to have far more benefit than risk? Certainly, it is wise to seek guidance from an educated #herbalist, or a licensed healthcare provider on your team who also has advanced knowledge in botanical medicine, which I are happy to offer my clients.

References

Duda, R. B., Zhong, Y., & Navas, V. (1999). American ginseng and breast cancer therapeutic agents synergistically inhibit MCF-7 breast cancer cell growth. Journal Surgical Oncology, 72(4), 230-239.

Eliza, W. L., Fai, C. K., & Chung, L. P. (2012). Efficacy of Yun Zhi (Coriolus versicolor) on survival in cancer patients: systematic review and meta-analysis. Recent Pat Inflamm Allergy Drug Discov, 6(1), 78-87.

Iino, Y., Yokow, T., & Maemura, M. (1995). Immunochemotherapies versus chemotherapy as adjuvant treatment after curative resection of operable breast cancer. Anticancer Res, 15(16B), 2907-2911.

Kelber, O., Neiber, K., & Kraft, K. (2014). Valerian: no evidence for clinically relevant interactions. Evid Based Complement Alternative Medicines, 2014, 879396.

King, M. L., Adler, S. R., Murphy, L. L. (2006). Extraction-dependent effects of American ginseng (Panax quinquefolium) on human breast cancer cell proliferation and estrogen receptor activation. Integr Cancer Ther, 5(3), 236-243.

Mach, C. M., Chen, J. H., Mosley, S. A., Kurzrock, R., & Smith, J. A. (2010). Evaluation of liposomal curcumin cytochrome p450 metabolism. Anticancer Res, 30(3), 811-814.

Marx, W. M. Teleni, L., & McCarthy, A L. (2013). Ginger (Zingiber officinale) and chemotherapy-induced nausea and vomiting: a systematic literature review. Nutr Rev, 71(4), 245-254.

Panahi, Y., Saadat, A., Beiraghdar, F., & Sahebkar, A. (2014). Adjuvant therapy with bioavailability-boosted curcuminoids suppresses systemic inflammationa nd improves quality of life in patients with solid tumors: a randomized double-blind placebo-controlled trial. Phytother Res, 28(10), 1461-1467.

Pommier, P., Gomez, F., & Sunyach, M. P. (2003). Phase III randomized trial of Calendula officinalis compared with trolamine for the prevention of acute dermatitis during irradiation for breast cancer. Journal Clinical Oncology, 22(8), 1447-1453.

Qiu, J. X. Zhou, Z. W., & He, Z X. (2015). Estimation of the binding modes with important human cytochrome P450 enzymes, drug interaction potential, pharmocokinetics, and hepatotoxicity of ginger components using molecular docking, computational, and pharmacokinetic modeling studies. Drug Des Devel Ther, 9, 841-866.

Ryan, J. L., Heckler, C. E., & Roscoe, J. A. (2012). Ginger (Zingiber officinale) reduces acute chemotherapy-induced nausea: A URCC CCOP study of 576 patients. Support Care Cancer, 20(7), 1479-1489.

Scontre, V. A., Martins, J. C., & Vaz de Melo Sette, C. (2018). Curcuma longa (turmeric) for prevention of capecitabine-induced hand-foot syndrome: a pilot study. Journal of Dietary Supplements, 15(5), 606-612.

Sharp, L., Finnila, K., Johansson, H., Abrahamsson, M., Hatschek, T., & Bergenmar, M. No differences between Calendula cream and aqueous cream in the prevention of acute radiation cream in the prevention of acute radiation skin reactions - results from a randomised blinded trial. European Journal of Oncology Nursing, 17(4), 429-435.

Toi, M., Hattoir, T., & Akagi, M. (1992). Randomized adjuvant trial to evaluate the addition of tamoxifen and PSK to chemotherapy in patients with primary breast cancer. 5-year results from the Nishi-Nippon Group of the Adjuvant Chemoendocrine Therapy for Breast Cancer Organization. Cancer, 70(10), 2475-2483.

Wolf, R., Heckler, C. E., & Guido, J. J. (2018). Oral curcumin for radiation dermatitis: a URCC NCORP study of 686 breast cancer patients. Support Care Cancer, 70(10), 1543-1552.

Zhu, W., JIa, L., Chen, G., & Zhao, H. (2013). Epigallocatechin-3-gallate ameliorates radiation-induced cute skin damage in breast cancer patients undergoing adjuvant radiotherapy. Oncotarget, 7(30), 48607-48613.