Integrative Team Approach To Breast Carcinoma
by Mitchell J. Ghen, D.O., Ph.D., Richard S. Leff, M.D., F.A.C.P., Susan E. Kolb, M.D., F.A.C.S.,
Li Hua, T.C.M.M., Cliff Steagall, P.T., Sandy Goldring, M.S., P.T., Wesley Anderson, D.C.H.

Introduction

If you are a woman you are at significant risk for getting breast cancer. Twenty years ago medical schools taught that one out of every eleven women would contract breast carcinoma with one out of every 7 who had cancer in one breast would have a second occurrence in the other breast. In contrast in 1950, one out of every twenty women would have a chance of developing this problem. Today the statistics are much more moribund. In 1998 the American Cancer Society stated that lifetime risk to get any type of cancer is one out of every three. For women ages 15 to 54 breast cancer is the number one culprit (Reyes, 1999) with one out of every 8 women developing neoplasia of the breast. (Fitzgerald, 1997) Advances in conventional medicine have improved survival in the early stages of this disease. The incidence of breast cancer is generally rising in this country and the risk from dying has remained static for the last 60 years. Outcomes in metastatic disease utilizing conventional treatment has not improved survival. (Diamond, 1996) Side effects of most traditional therapies has lead cancer patients (70%) to seek alternative/natural therapies.

Our exposure to large quantities of carcinogens in our daily life has increased our potential for breast carcinoma. D.D.T., a well-known pesticide, still used in many parts of the world has been shown to increase breast cancer risk. Israeli women had a particularly high prevalence of this disease before the ban of this pesticide. Israeli dairy products had previously 100% - 800% greater D.D.T. residues in their dairy products than the United States. (DeMarco, 1997)

Organo-chlorines highly toxic chemicals used to make P.V.C. plastics, solvents and pesticides become concentrated in the fatty tissues. More than 177 organo-chlorines have been found in the tissues of the general population in this country. (DeMarco, 1997)

In addition to exogenous toxins as described heavy metal accumulation within the cells can inhibit cellular nutrition and function. Exposure to and levels of aluminum, mercury, lead, cadmium, arsenic and antimony in your body is assured if you are 40 years or older.

Estrogens that oxidize may also damage the DNA and therefore promote cancer. (Zelig, 1999)

We have found that although the cell type may be similar from individual to individual the presentation in terms as far as the disease progression, side effects, rate of metastasis and response to treatment are often very different. Factors are so varied that treatment protocols often must be adapted to allow for the significant variance that is seen.
We believe a multi-discipline, integrative approach for breast carcinoma offers the most logical and practical solution for treatment. Our experience suggests that utilizing an all-inclusive program the patient can expect the best of both worlds and therefore the very best of overall success.

ALLOPATHIC/CONVENTIONAL APPROACH

Conventional care of breast cancer is 1999 is based on a coordinated approach of prevention, genetic risk assessment, screening for early detection, limited surgical therapy, adjuvant treatment to reduce the risk of recurrence and aggressive management of advanced disease. All of these areas have evolved significantly over the past decade and have improved the outcome of women with breast cancer as well as presenting the opportunity for many women at risk to avoid this serious disease.

Breast cancer prevention is not a new concept, but studies completed in 1998 have demonstrated that active pharmacological intervention can significantly reduce the risk of breast cancer. For many years it has been clear that risk can be modified by changes in behavior including diet modulation, reducing fat intake, and reducing alcohol intake. In 1998 a large national study, conducted by the NSABP (National Surgical Adjuvant Breast and Bowel Project, a cooperative group consisting of almost 300 member medical centers and 6000 medical professionals), demonstrated that Tamoxifen, an estrogen blocking compound, could reduce the incidence of breast cancer in women at significant risk by almost 50% over a 5 year period. At the same time, a study in Europe examining the role of Raloxifene in treatment of osteoporosis demonstrated a similar decrease in breast cancer incidence. This drug, a selective estrogen receptor modulator (SERM), simultaneously stimulates some estrogen-dependent functions (bone mineralization and cholesterol suppression) while inhibiting others (breast cancer growth and uterine stimulation). A large national study, the STAR trial, comparing the effectiveness and toxicities of these 2 drugs has just started and is open to women at increased risk for breast cancer. Use of this pharmacological approach in conjunction with lifestyle and dietary changes may significantly reduce the risk of breast cancer in the future.

Recent advances in the understanding of the genetics of breast cancer has led to the ability to identify families at very high risk for developing this cancer as well as cancer of the ovaries. Less than 10 percent of breast cancer cases are related to a mutation in one of 2 breast cancer genes recently characterized, however, women carrying one of these genetic abnormalities may be at very high risk for developing cancer, up to 80%. These genes, BRCA1 and BRCA2, can be identified most often in families with a history of breast cancer before age 50, bilateral breast cancer and multiple family members with breast cancer, other family members can be screened for the abnormality by a blood test. Women carrying the gene may choose bilateral mastectomy to prevent breast cancer and may opt for removal of their ovaries once child bearing has been completed. Although this applies to a small minority of patients with breast cancer, it is a very important advance for families with genetic predisposition to this malignancy. When primary prevention has failed, screening for early detection becomes the next line of defense. Monthly self exam in conjunction with annual mammograms has shifted the profile of the typical breast cancer patient to one with a small tumor, frequently less than 2 cm. The size of the tumor at diagnosis is critically linked to the likelihood that cancer cells have spread elsewhere in the body (metastasized). A very small tumor can frequently be cured by surgical excision (lumpectomy) and radiation without chemotherapy or hormonal therapy. Larger tumors may also be treated with lumpectomy and radiation but are associated with a higher risk of metastasis which may be reduced by chemotherapy. Mammography has been improved so that there is an increase in effectiveness and safety. Newer techniques for early detection of breast cancer, including a blood test, are not yet completely proven but are on the horizon. Surgical treatment of breast cancer has evolved a great deal in the past 15 years. Up until the early 1980's all women in the United States with breast cancer underwent mastectomies for surgical treatment of their malignancies. Studies in Italy and later in the United States have proven that lumpectomy and radiation therapy achieves the same cure rate as mastectomy. Although this procedure is not appropriate for all women, the use of lumpectomy exceeded mastectomy in many areas of the United States in 1997.

Sentinel node biopsy is another very exciting and promising surgical technique under investigation. Since information about the status of the axillary lymph nodes is very important in determining the prognosis and deciding about use of chemotherapy, removal of lymph nodes from under the arm has been a universal part of mastectomies and lumpectomies.

Unfortunately, this procedure is sometimes associated with significant lymphedema (chronic swelling of the arm). Alternative disciplines may often improve this uncomfortable side-effect. A new technique, using injection of a dye or radioactive material at the tumor site, allows the surgeon to identify the first lymph node filtering cells exiting the breast through lymphatic veins. Ongoing studies have shown that removal of this node and examination with sophisticated immunologic stains can predict which women need to have additional lymph nodes removed. Although this technique is still considered investigational, once further studies have confirmed its accuracy many women will be spared the potential toxicity of axillary lymph node sampling.

Knowledge about the natural history of breast cancer has allowed cancer specialists to predict the risk of occult distant spread at the time of initial diagnosis and surgical therapy. Risk factors for spread include lymph node involvement, large tumor size and the absence of tumor cells' ability to bind estrogen and progesterone. In addition, the presence of increased amounts of a receptor called HER2/new, abnormal amounts of DNA in tumor cells and a high fraction of cells in growth phase (S-Phase) are risk factors for occult spread of breast cancer cells. Using this information, oncologists can approximate the risk of developing metastatic cancer and recommend postoperative chemotherapy and hormonal therapy to reduce this risk. This type of treatment, termed adjuvant therapy, can significantly reduce the risk of developing metastatic cancer. Statistics about risk and specific characteristics of the tumor cells allow tailoring of therapy to optimize the chance of cure. Addition of a new drug, Taxol, has improved the outcome of some subsets of women receiving adjuvant chemotherapy. In addition, recent studies have shown that women with positive lymph nodes who have the HER2/neu receptor amplified on their tumor cells benefit from the inclusion of Adriamycin in their chemotherapy regimen and respond less often to Tamoxifen. Women with high numbers of involved lymph nodes (more than 10) receive more aggressive treatment regimens, sometimes involving use of stem cell transplantation. Early results from randomized controlled studies of aggressive chemotherapy versus high dose chemotherapy with bone marrow or stem cell transplantation have yielded inconclusive results. One study suggests a clear early advantage for the transplant approach while another with short follow up shows no definite advantage. Additional follow up of those studies as well as additional studies will be needed to settle this controversy. Tamoxifen remains a mainstay of therapy for older women with breast cancer with cells able to bind estrogen. Although Raloxifene is being studied in the role of primary prevention, previous studies comparing this drug with Tamoxifen in women with metastatic breast cancer have shown inferior results for Raloxifene so that oncologists are reluctant to sue it for women at risk for developing metastases.

In 1998 Herceptin, the first antibody for treatment of breast cancer, became available for clinical use. This immunologic agent which is used in the setting of metastatic cancer is only effective in women whose tumor cells demonstrate increased amounts of HER2/neu. It appears to be most effective when used in conjunction with chemotherapy including either Adriamycin or Taxol. Unfortunately, the combination of either of these drugs with Herceptin can result in development of heart failure. This side effect can be mitigated by the inclusion of Co-enzyme Q10, L-Carnitine and Taurine supplementation. Cardiac function must be closely observed during this treatment. Nonetheless, Herceptin has increased the likelihood of responding to either of these chemotherapies as well as the median duration of response to treatment.

Aside from chemotherapy, symptomatic palliative care for patients with metastatic breast cancer has also improved over the last decade. Aredia, a drug which "hardens" bones is now a standard therapy in women with cancer which has spread to bone. It helps to prevent or delay spread of the cancer in the bones and reduces the incidence of bone "events" such as fractures and pain. New pain medications which depend on slow release of oral medications have dramatically improved the ability to control pain. Couple these pain medications with oxygenating therapies orally and particularly IV will improve the effectiveness of these analgesics. Essential fatty acids supplementation should also be used to encourage the PGE-1 pathway. IV use of H.E.P.A. can also reduce P-factor and therefore pain. New chemotherapy drugs, including Navelbine and Xeloda, have expanded the oncologist's treatment resources and helped to improve both the quality and length of patients' lives.

Breast cancer is a serious public health and human problem in the United States. Rapid change is occurring in the management of this disease.

ALTERNATIVE TREATMENT

• Common Elements: Common elements of alternative medicine for breast cancer treatments include the avoidance of alcohol, drugs, tobacco, red meat and caffeine. We suggest that patients minimize and avoid chemicals such as aluminum found in antiperspirants, white flour (used as anti-caking agents), antacids and aluminum pots and pans. We ask patients to respect pesticides and handle them with care and if possible minimize their exposure to these and other chemicals in their environment. Eating organic and non-irradiated food is important as well. Nutritional considerations stress the importance of purified, filtered water made daily preferably from reverse osmosis. Fresh raw fruits, avoiding sugars, fats and processed foods is also warranted. Essential fatty acids should be part of the diet and the protective role of phyto and or plant estrogens in breast cancers is also noted. Everyday patients with breast cancer should eat the cruciferous vegetables (cauliflower, cabbage, brussel sprouts and broccoli) which are high in di-indolylmethane which have been shown to at least help prevent breast cancer by reducing the activity of the estrogen receptor system, (Zelig, 1999) promote good estrogen metabolism and support selective apoptosis. (Talang, 1997)

• Nutritional Supplements especially those that boost the immune system need to be included such as Vitamin E, Vitamin C, Selenium, B-Complex, mixed Carotenoids, Bio-Flavanoids, Co-enzyme Q-10 and enzymes to aid in digestion. Substances that increase natural killer cell function are also helpful such as Acemannin, IP-6 and MGN-3.

• Beverages should include liberal quantities of Cat's Claw which has antioxidants and anti-tumor properties and EssiacHerbal Tea, which strengthens the immune system and contains the herbs, Burdock, Indian Rhubarb, Sheep Sorril and Slippery Elm. The chemical substances in Green Tea not only contain bio-flavanoids but also substances that have tumoricidal effect.

• Detoxification programs should also be considered particularly in the early stages of treatment with meticulous detail to those items that improve and encourage the detoxification pathways, phases one and two. If patient's have a hair analysis high in a particular heavy metal then consider a chelating agent that is specific for this heavy metal. If significantly high mercury levels are demonstrated than chelation along with amalgam removal (if present) should also be recommended.

• Most cancer patients exhibit significant poor cellular nutrition and will require IV (intravenous) vitamin and mineral repletion. Otherwise suboptimal nutriture deficiencies will not be remedied.

• Oxidative therapies that improve cellular oxygenation include hydrogen peroxide, ozone (03) and CL4.

• Photoluminescence also known as ultraviolet irradiation of the blood uses a UV light box to irradiate the blood with UVB and UVA light. It has been shown to have a positive effect on reducing bacteremia, viremia and cancer cells. The induction of cytokines and interferons should also be expected. (Rowen, 1996)

• Ukraine is an intravenous compound of Chelidonium Majus and Thiophosphoric acid triaziridide. This substance has been shown to have cytostatic and cytolytic activity. Improvement in the T4/T8 ratio, activation of the natural killer cells (NKC) and increasing migratory phagocytosis has also been seen in certain white blood cell lines. No leukopenia or thrombocytopenia has been reported with this therapy. Extracts of the herb Misteltoe, use din conjunction with Ukraine, can significantly stimulate the immune system. Ukraine should not be used concurrently with other conventional chemotherapeutic agents. (Ukraine package insert)

• Hypnotherapy and hypnotherapists do not diagnose or directly treat cancer. Hypnotherapy, however, is useful and safe as an adjunct for cancer therapy. For those patients electing surgery, hypnotherapy for pre-surgery preparation can lessen the need for preoperative medicines and postoperative pain medication. (Kolough, 1962) Hypnosis allays fear and tension reducing anoxemia and facilitates the induction of chemical anesthesia reducing the amounts of chemical anesthesia and analgesia needed. Hypnosis can be of great value in controlling intractable pain of the cancer patient and lessening the discomfort following radiation therapy. (Dempster, 1976) The need for opiates can be reduced through post-hypnotic suggestion, auto-hypnosis and glove anesthesia. Hypnosis can be used to support a strong will to live and have a powerful impact on the emotional factors associated with cancer. (Meerlo, 1954) The field of psychoneuroimmunology postulates that there are a number of pathways by which the mind and emotions affect the immune system. (Rossi) There are specific hypnotic techniques that have been developed for cancer treatment that involve enhancing the immune system by visualizing cells being 'killed or dissolved' by the "good guy" cells of the immune system. The hypnotherapist would address any limiting beliefs or negative attitudes while assisting the patient and building an optimistic mindset in regards to their therapies that they are receiving.

• Colon therapy can play an important role in treating breast cancer when it is part of an integrative and complementary team approach. There are no current scientific studies that can prove conclusively that colon hydrotherapy or therapeutically alter neoplastic cells. However, many health authorities believe that disease begins in the colon. The growth of excessive pathogenic organisms can injure the intestinal wall and lead to 'leaky gut syndrome'. This condition results from the increased intestinal permeability which allows fragments of injurious antigenic food proteins and bacterial breakdown products to leak into the blood stream. (Galland, Inman & Katz, 1993) These foreign common inflammations-inciting substances can in turn, exacerbate arthritis, lupus, and other autoimmune diseases. Dr. Lang of the Royal Society of Great Britain has said, "auto-intoxication plays so large a part in the development of disease of the female genito-urinary apparatus, that they may be regarded by the gynecologist as a product of intestinal stasis." One of the functions of colon therapy is to assist in the removal of toxins from the body. The colon has become a site desperately in need of detoxification largely due to the accumulation of endo and exotoxins. According to Jeffrey Bland, Ph.D., "chronic illness might be the result of an accumulation of endo and exotoxins in conjunction with the chronically ill person's lack of ability to effectively detoxify and eliminate those substances." Colon therapy is an excellent method of accessing the very large lymphatics of the mesenteric and portal ducts to stimulate the release of interstitial waste products and potent toxins that would otherwise be stored in adipose and myelin tissues, thereby weakening the immune system and setting the stage for chronic illness and cancer. (Dixon, 1999)

• Traditional Chinese Medicine (TCM) is one of the oldest medicines in the world. It consists of herbs, acupuncture-moxibustion, cupping and Chinese medical massage. (Tue Na), Philosophy of TCM suggests that stagnation of blood and chi as well as the imbalance of the seven emotions are the main reasons that cause breast cancer. TCM treats breast cancer by first removing the stagnation of Chi and Blood and balancing the seven emotions. Secondly, it attempts to improve immunity and encourage patients to go on a proper diet and exercise program. TCM treats breast cancer differently for each patient creating special and individualized plans depending on each person's needs. TCM is safe and will work with most other therapies such as chemotherapy, radiation therapy and surgery. However, interactions of Chinese herbs with other conventional medicines, vitamins, minerals and Western herbs must be considered. TCM has been shown to improve energy, depression, poor appetite or other uncomfortable symptoms. TCM can improve the immunity of the individual while improving energy by activating the spirit.

• Feldenkrais or the Feldenkrais Method is a form of sensorimotor education. Feldenkrais (rhymes with "rice") trains the nervous system to find alternatives to the habitual, uncomfortable patterns that impair optimal function. Feldenkrais is not considered a type of therapy or medical intervention but benefits are merely side effects of the learning process. Breast cancer patients that have had a mastectomy can expect a faster recovery from surgery when using this technique. Feldenkrais is renowned for helping people improve their mobility without increasing their discomfort, thus it can serve as a useful adjunct to physical therapy.

Cancer patients can benefit from stress management programs. (Fawzi, 1995) Feldenkrais lessons are extremely relaxing and the Method has been successfully utilized for stress management in clinical settings. (Chase, 1998)

Each student learns how to experience herself as an integrative whole rather than as a collection of parts. Cancer patients may perceive themselves as engaging in combat with the bodily components which have tuned against them. Mastectomy in particular can leave women feeling incomplete and unattractive. Research suggests that Feldenkrais can help women form a more complete, positive self-image and improve self-acceptance. (Deig, 1994 & Laumer, 1997)

• Psychoneuroimmunology explains the intricate relationship between the central nervous system and the target organs like the adrenal glands and the functioning of the white blood cells. (Moye, 1995) We encourage this healthy relationship by utilizing disciplines that will improve interrelationship of the mind, neurologic, endocrine and immune systems. In addition to hypnotherapy consider guided imagery classes, neurolinguistic programming, meditation and Kabbalah. (Sporotny, 1997)

Summary
The approach described above is utilized since it incorporates traditional and alternative perspectives. Primary prevention, early detection, appropriate surgical, radiologic intervention, aggressive adjuvant therapy and alternative/complementary immune support can save the lives of many women. New developments on the horizon should continue to extend the gains made over the past 20 years. Someday in the future with improved nutrition, lifestyles, prevention and detection, death from breast cancer will become a historical oddity. The overall review of this treatment program reflects the logical and rational approach as described by Ghen in his "Ghen Hypothesis" which suggests cellular nutrition, cellular respiration, hormonal balance, energy balance and psychosocial aspects be considered simultaneously in order for the patient to obtain optimal health.

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