Related Terms

• Axillary, chemobrain, computer-aided detection, ductal carcinoma in situ (DCIS), ductal lavage, estrogen, fibroadenomas, fibrocystic, fine needle aspiration, HER-2/neu, infiltrating ductal, infiltrating lobular cancer, inflammatory breast cancer, invasive ductal, lumpectomy, lymph node, magnetic resonance imaging, mammography, mastitis, medullary carcinoma, metastatic, microcalcification, molecular breast imaging, mucinous carcinoma, peau d' orange, tubular carcinoma, ultrasonography.

Background

• In breast cancer, some cells begin growing abnormally. The cells divide more rapidly than healthy cells and may spread through the breast tissue to the lymph nodes or other parts of the body (metastasize). The most common type of breast cancer begins in the milk-producing ducts, but cancer may also occur in the lobules or in other breast tissue.

• According to the National Cancer Institute (NCI), breast cancer is the second leading cause of cancer death in American women.

• In the United States, it is estimated that 12% of American women will develop the disease and 3.5% will die from it.

• The incidence of breast cancer varies with age being very low in the twenties, gradually increasing and reaching a plateau at the age of 45 and then increasing dramatically after fifty. Breast cancer is diagnosed in women over 65 years 50% of the time, indicating the ongoing necessity for women to have yearly screenings.

• Although rare, breast cancer may also occur in men. In men, breast cancer can occur at any age, but is most common between the ages of 60 to 70 years. For every 100 cases of breast cancer, less than 1 is found in men.

• Breast cancer is considered a heterogeneous disease, meaning that it is a different disease in different women, a different disease in different age groups and has different cell populations within the tumor itself. Generally, breast cancer is a much more aggressive disease in younger women.

• There are many different varieties of breast cancer. Some cancer cells are fast growing while others are slow. Some cancer cells are stimulated by the estrogen in the body while others result from an out-of-control oncogene (cancer gene). Treatment is based on the special characteristics of the breast cancer.

• Stage 0: Stage 0 is when the cancer has not spread from the breast tissue. Stage 0 may also be known as noninvasive carcinoma or carcinoma in situ. Lobular carcinoma in situ (LCIS) refers to abnormal cells in the lining of a lobule that seldom become invasive cancer. Their presence is a sign that a woman has an increased risk of developing breast cancer, and this risk of cancer is relevant for both breasts.

• Ductal carcinoma in situ (DCIS): DCIS refers to abnormal cells in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread beyond the duct invading the surrounding breast tissue, but women with DCIS remain at an increased risk for invasive breast cancer. The most common type of breast cancer is ductal carcinoma. Both DCIS and LCIS are classified as Stage 0.

• Stage I and II: Stage I and stage II are early stages of breast cancer in which the cancer has spread beyond the lobe or duct invading nearby tissue. Stage I means that the tumor is no more than one inch across, and has not spread beyond the breast. Stage II means that the tumor in the breast is less than 1 inch across and the cancer has spread to the lymph nodes under the arm, that the tumor is between 1 and 2 inches across with or without infiltration to lymph nodes under the arm (called Stage IIa), or that the tumor is larger than 2 inches across, but has not spread to the lymph nodes under the arm (called Stage IIb).

• Stage III: Stage III is also known as locally advanced cancer. In this stage, the tumor in the breast is smaller or larger than 2 inches and has spread to the lymph nodes under the arm and is extensive in the underarm lymph nodes (called Stage IIIa), or the cancer has spread to lymph nodes near the breastbone, muscles, and other tissues near the breast (called Stage IIIb). In stage IIIc, the tumors have spread to lymph nodes beneath the collarbone, lymph nodes near the neck, lymph nodes within the breast or under the arm, and to tissues near the breast. This stage may be operable dependent upon its location.

• Stage IV: Stage IV is metastatic cancer. The cancer has spread beyond the breast and underarm lymph nodes to other parts of the body. The five-year survival rate for cancer diagnosed at this stage is 5 to 10%.

• Recurrent cancer: Recurrent cancer means the disease has come back in spite of the initial treatment. Even when a tumor in the breast seems to have been completely removed or destroyed, the disease may return due to undetected cancer cells that remained in the body following treatment. Most recurrences appear within the first two or three years after treatment, but breast cancer can develop many years later.

• Cancer appearing in the area of the original surgery is called a local recurrence. If the disease returns in another part of the body, the distant recurrence is called metastatic breast cancer. The patient may need a combination of treatments for recurrent cancer.

• Infiltrating or invasive ductal: Infiltrating ductal is the most common type of breast cancer, representing 78% of all malignancies. These lesions can have a star-like appearance on mammography or be well rounded. The star-like lesions generally have a poorer prognosis.

• Medullary carcinoma: Medullary carcinoma comprises 15% of breast cancers. These lesions are generally well circumscribed, but may be difficult to distinguish from fibroadenomas on mammography or sonography. Medullary carcinoma is estrogen and progesterone receptor (prognostic indicator) negative 90% of the time. Medullary carcinoma usually has a better prognosis than ordinary breast cancer.

• Infiltrating or invasive lobular: Infiltrating lobular cancer represents 15% of breast cancers. The lesions are generally found in the upper outer quadrant of the breast as a slight thickening, and are difficult to diagnose by mammography. Infiltrating lobular cancer can occur bilaterally (involve both breasts).

• Tubular carcinoma: Tubular carcinoma is categorized as an orderly or well-differentiated carcinoma of the breast. These lesions make up about 2% of breast cancer. They have a favorable prognosis with a ten-year survival rate of nearly 95%.

• Mucinous carcinoma: Mucinous carcinoma has well rounded lesions, a favorable prognosis, and represents 1 to 2% of breast cancers.

• Inflammatory breast cancer (IBC): IBC is a particularly aggressive type of breast cancer. It is usually found due to skin changes of the breast including redness (erythema), thickening of the skin, and prominence of the hair follicles resembling an orange peel. The diagnosis is made by a skin biopsy, which 50% of the time reveals tumors in the lymphatic and vascular channels. The five-year median survival rate for inflammatory breast cancer is approximately 40%.

• Breast cancer is generally treated with surgery, irradiation, and chemotherapy.

Risk Factors

• Age: The chances of developing breast cancer increases with age. The disease rarely affects women younger than 25 years of age, whereas close to 80% of breast cancers occur in women older than age 50. At age 40, there is a one in 252 chance of developing breast cancer. By age 85, the chances are one in eight.

• A personal history of breast cancer: If an individual has had breast cancer in one breast, there is an increased risk of developing cancer in the other breast.

• Family history: If the individual's mother, sister, daughter or male relative has had breast cancer, ovarian cancer, or both, the risk of developing breast cancer is doubled. In general, the more relatives one has with breast cancer that were premenopausal at the time of diagnosis, the higher the risk.

• Genetic predisposition: Between 5 and 10% of breast cancers are inherited. Defects in one of several genes, especially BRCA1 or BRCA2, put the individual at a greater risk for developing breast, ovarian and colon cancers. Usually these genes help prevent cancer by making proteins that keep cells from growing abnormally, but if they are mutated, then the genes aren't effective at protecting the individual from cancer.

• Radiation exposure: Radiation treatments to the chest experienced as a child or young adult may increase in the risk of developing breast cancer later in life. The younger the individual was when they received the treatments the greater the risk.

• Excess weight: The relationship between excess weight and breast cancer is complex. In general, weighing more than what is normal for the patient's age and height increases the risk of breast cancer, especially if the patient has gained the weight as an adult or in postmenopause. The risk is even greater if the excess fat is in the upper part of the body. Although women usually have more fat in their thighs and buttocks, they tend to gain weight in their abdomens in their 30s, which can increase their risk of developing breast cancer.

• Exposure to estrogen: The longer an individual is exposed to estrogen, the greater the risk of breast cancer. In general, if an individual has a late menopause (after age 55) or early menses (before age 12), there is a slightly higher risk of developing breast cancer. Women who never had children or whose first pregnancy occurred when they were age 35 or older also have an increased risk of developing breast cancer.

• Race: Caucasian women are more likely to develop breast cancer than African-American or Hispanic women. However, African-American women are more likely to die of the disease because their cancers are found at a more advanced stage. Although some studies show that African-American women may have more aggressive tumors, socioeconomic factors may enter the picture also. Women of all races with incomes below the poverty level are often diagnosed with late-stage breast cancer, and are more likely to die of the disease than women with higher incomes. Low-income women don't usually receive the routine medical care that would allow breast cancer to be discovered earlier.

• Hormone therapy: A study sponsored by the National Institutes of Health (NIH) in June 2002 was halted as researchers reported that hormone therapy, once considered standard treatment for menopausal symptoms, actually posed more health risks than benefits. Along with an increase in cardiovascular disease and uterine cancer, there was a slightly higher risk of breast cancer for women taking the particular combination of hormone therapy (estrogen plus progestin) used in the study. In addition, combination hormone therapy can make malignant tumors harder to detect on mammograms, leading to cancers that are diagnosed at more advanced stages when they're more difficult to treat.

• Birth control pills: The hormone therapy studies have raised questions about the relationship between birth control pills and breast cancer. Studies have reported that women who are currently using birth control or have used them in the past 10 years are at a slightly increased risk for having breast cancer in the next 10 years. These cancers tend to be localized to the breast and are less clinically advanced than the cancers diagnosed in women who never used birth control pills.

• Smoking: Studies have found that smoking does increase the incidence of breast cancer in those with the genetic predisposition. More than 30 carcinogenic chemicals are present in tobacco smoke; many of which are fat-soluble, resistant to metabolism and can be stored in breast adipose tissue. A study published in 2001 found that smoking significantly increases the risk of breast cancer in women with a family history of breast and ovarian cancers. A more recent study found that exposure to secondhand smoke also increases the risk of breast cancer in premenopausal women. Researchers hypothesize that higher estrogen levels combined with the cancer-causing agents in tobacco spark the development of breast tumors.

• Other carcinogens: Polycyclic aromatic hydrocarbons are chemicals found mainly in cigarette smoke and charred red meat. Studies have shown that exposure to these chemicals can significantly increases the chances of developing breast cancer. Exposure to certain pesticides may also increase the risk.

• Excessive use of alcohol: Women who consume more than one alcoholic drink a day have about a 20% greater risk of breast cancer than women who don't drink. The National Cancer Institute recommends limiting alcohol intake to no more than one drink per day.

• Precancerous breast changes (atypical hyperplasia, carcinoma in situ): These changes are often discovered only after a breast biopsy is performed, and they can double the risk of developing breast cancer.

Causes

• The precise cause of breast cancer is unknown. Most cases of breast cancer occur in women who are not classified as high risk. More research must be done in order to uncover other possible causes.

• Genetics: In most cases, it isn't clear what triggers abnormal cell growth in breast tissue, but it is estimated that between 5 and 10% of breast cancers are inherited. Having a mother and/or a sister with the disease increases the risk. About a quarter of breast cancer cases occur in women who have the disease in the family. Defects in one of two genes, breast cancer gene 1 (BRCA1) or breast cancer gene 2 (BRCA2), put an individual at a greater risk of developing both breast and ovarian cancer. Inherited mutations in the ataxia-telangiectasia mutation gene, the cell-cycle checkpoint kinase 2 (CHEK-2) gene and the p53 tumor suppressor gene also make it more likely that an individual will develop breast cancer.

• Genetic mutations may result from radiation exposure. Women treated with chest radiation therapy in childhood, for instance, have a significantly higher incidence of breast cancer than women not exposed to radiation. Mutations may also develop as a result of exposure to cancer-causing chemicals, such as the polycyclic aromatic hydrocarbons found in tobacco and charred red meats.

• Estrogen: The female hormone estrogen is linked to breast cancer. The role of estrogen and its relation to breast cancer is not yet completely understood. If the individual has never given birth, they are at greater risk for breast cancer because of more exposure to estrogen than women who have had a baby. This is because the body produces less estrogen when one is pregnant. Taking estrogen after menopause (hormone replacement therapy: HRT) also increases the risk. It is important to remember that taking estrogen after menopause also increases the long-term risk of heart disease, uterine cancer, and stroke.

• Diet: Some studies suggest that a diet high in animal fat and protein may cause breast cancer, although the results of these studies are not definite.

• Others: Other research has focused on certain preservatives (parabens) that are used in deodorants and antiperspirants, as well as many cosmetics, foods, and pharmaceutical products. A study did not show any increased risk for breast cancer in women who reported using an underarm antiperspirant or deodorant. Some chemicals in the environment may mimic estrogen in the body which that may lead to breast cancer.

Signs and Symptoms

• Common signs and symptoms of breast cancer include a lump in the breast that feels distinctly different from other breast tissue or that does not go away, swelling of the breast that does not go away, thickening of breast tissue, dimpling or pulling of the skin on the breast which may then resemble the skin of an orange, any change in the breast shape or contour, nipple discharge, retraction of the nipple, scaliness of the nipple, pain or tenderness of the breast, and swollen bumps or puss-filled sores.

• Fibrocystic changes: This condition can cause the breasts to feel ropy or granular. Fibrocystic changes are extremely common, occurring in at least half of all women. In most cases the changes are harmless. If the breasts are very lumpy, then performing a breast self-exam is more challenging.

• Cysts: These are fluid-filled sacs that frequently occur in the breasts of women ages 35 to 50. Cysts can range from very tiny to about the size of an egg. They can increase in size or become more tender just prior to menstruation, and may disappear completely after. Cysts are less common in postmenopausal women.

• Fibroadenomas: These are solid, noncancerous tumors that often occur in women during their reproductive years. A fibroadenoma is a firm, smooth, rubbery lump with a well-defined shape. It will move under the skin when touched, and is usually painless. Over time, fibroadenomas may grow larger, smaller or even disappear completely.

• Infections: Breast infections (mastitis) are common in women who are breastfeeding or who have recently stopped breastfeeding, but mastitis may develop when women are not nursing. The breast will likely be red, warm, tender and lumpy, and the lymph nodes under the arm may swell. The individual may also feel slightly ill and present with a low-grade fever.

• Trauma: Sometimes a blow to the breast or a bruise also can cause a lump, but this doesn't mean the individual is more likely to get breast cancer.

• Calcium deposits (microcalcifications): These tiny deposits of calcium can appear anywhere in the breast and often show up on a mammogram. Most women have one or more areas of microcalcifications of various sizes. They may be caused by secretions from cells, cellular debris, inflammation, trauma or prior radiation. Calcium deposits are not the result of taking calcium supplements. The majority of calcium deposits are harmless, but a small percentage may be precancerous or cancer.

• Inflammatory breast cancer (IBC): Symptoms of IBC can include one breast larger than the other, red or pink skin, swelling, rash (entire breast or small patches), orange-like texture (peau d' orange), skin hot to the touch, pain and/or itchiness, ridges or thickened areas of breast, nipple discharge, nipples that appear inverted or flattened, swollen lymph nodes under the armpit, and sometimes swollen lymph nodes of the neck.

Diagnosis

• Early detection remains the best way to prevent debilitation and death from breast cancer. Traditionally, mammography, clinical breast examinations (CBE), and breast self examinations (BSE) have been accepted as legitimate breast screening modalities.

• Genetic testing: Women with BRCA1 or BRCA2 (both primary genes involved in breast cancer) genetic mutations may be advised to begin screening at age 25 because of their increased risk for developing breast cancer.

• Breast self-examination (BSE): In about 80% of breast cancer cases, the woman detects the lump herself. Women are advised to examine their breasts on a monthly basis starting around age 20. Women may be able to detect early signs of cancer if they become proficient at BSE and familiar with the usual appearance and feel of their breasts. A study did find that women who perform regular breast self-exams might be more likely to undergo unnecessary biopsies after finding breast lumps. Breast self-examination should be performed once a month at the same time each month, one week after a woman's period.

• Clinical breast exam (CBE): Unless there is a family history of cancer or other factors that place the individual at high risk, the American Cancer Society recommends having clinical breast exams once every three years until age 40. After that, the American Cancer Society recommends having a yearly CBE. During this exam, the doctor examines the breasts for lumps or other changes. He or she may be able to feel lumps missed by self-examination and will also look for enlarged lymph nodes in the armpit (axillary).

• Mammography: Overall mammography is a very effective breast cancer screening tool, and has the ability to detect breast cancers before they can be felt. It may be more effective at detecting tumors in older women than in younger women, and not all cancers can be detected by this method. Images on mammograms appear in gradations of black, gray and white depending on the density of the tissue. Bone shows up as white, fat appears dark gray, and cancerous tumors appear a lighter shade of gray or white.

• Unfortunately, dense normal breast tissue can also appear light gray on a mammogram, which can make mammograms harder to interpret in younger women, since they tend to have breast tissue that is denser. After menopause, though, breast density usually begins to decrease, making the mammograms of older women easier to read. For this reason, it is important to follow the guidelines for clinical breast examination (CBE) and to practice regular breast self-examination (BSE).

• If a lump in the breast is found, either by breast self-exam or mammography, other tests will be performed in order to make a diagnosis. The only proven way to reduce the risk of dying from breast cancer is by having regular mammograms after the age of 50.

• Computer-aided detection (CAD): Radiologists normally view X-rays and mammograms, and their skills and experience play a large part in determining the accuracy of the test results. In CAD, a computer scans the mammogram after a radiologist has reviewed it. CAD identifies more suspicious areas on the mammogram, but many of these areas may later prove to be normal. Using mammography and CAD together may increase the cancer detection rate.

• Digital mammography: In this procedure, an electronic process is used to collect and display X-ray images on a computer screen. This allows the radiologist to alter contrast and darkness, making it easier to identify subtle differences in tissue. In addition, the images can be transmitted electronically, so women who live in remote areas can have their mammograms read by an expert who is based elsewhere.

• Magnetic resonance imaging (MRI): MRI uses a magnet linked to a computer to take pictures of the interior of the breast. Although not used for routine screening, MRIs can reveal tumors that are too small to detect through physical exams or are difficult to see on conventional mammograms. Some centers may use MRI as an additional screening tool for high-risk women who have dense breast tissue on a mammogram. MRIs aren't recommended for routine screening because they have a high rate of false-positive results, which lead to unnecessary anxiety and biopsies. They are also expensive and not readily available.

• Ductal lavage: In this procedure, the doctor inserts a tiny, flexible tube (catheter) into the lining of a duct in the breast and withdraws a sample of cells. The cells are then examined for precancerous changes that might eventually lead to disease. These changes show up long before tumors can be detected on a mammogram. Ductal lavage isn't recommended as a screening tool for high-risk women. It is a new procedure with risks, including the rate of false-negative results and its inability to determine the exact location of abnormal cells and whether they will lead to cancer.

• Breast ultrasound (ultrasonography): The doctor may use this technique to evaluate an abnormality seen on a mammogram or found during a clinical exam. Ultrasound uses sound waves to form images of structures deep within the body. Because it doesn't use X-rays, ultrasound is a safe diagnostic tool that can help determine whether an area of concern is a cyst or solid tissue. Breast ultrasound isn't used for routine screening because it has a high rate of false-positive results.

• Molecular breast imaging (MBI): This experimental technique tracks the movement of a radioactive isotope that's taken up by breast tissue, particularly the tumors. Images are taken of the breast when the radioactive isotope signals are detected. In preliminary studies, MBI found small tumors that both mammography and ultrasound missed. This procedure uses lighter compression, and may be more comfortable than mammography. The MBI takes about 40 to 50 minutes as opposed to 15 minutes for a mammogram, and the procedure is more invasive due to the injection. It is still unclear how abnormal findings are biopsied, and the studies remain ongoing.

• Fine needle aspiration: A thin needle is inserted into the lump and a sample is withdrawn. This test helps to determine if the lump is fluid-filled (a cyst, usually not cancerous) or a solid tumor. It can be performed in a doctor's office with local anesthesia. The sample, regardless if it is fluid or solid, is sent to the laboratory for further analysis.

• Core biopsy: A larger needle is inserted into a lump or an abnormal area seen on a mammogram, and the tissue sample is removed. The sample is analyzed for cancer cells, and this procedure is usually performed at a hospital with local anesthesia.

• Surgical biopsy: The lump and surrounding tissue is removed surgically before being sent to a laboratory for analysis. This procedure needs to be done in a hospital with either a local or general anesthetic.

• Stereotactic biopsy. This technique is used to sample and evaluate an area of concern that can be seen on a mammogram, but cannot be felt or seen on an ultrasound. During the procedure, a radiologist takes a core needle biopsy using the mammogram as a guide. Stereotactic biopsy usually takes about an hour and is performed using local anesthesia.

• Wire localization. A doctor may recommend this technique when a worrisome lump is seen on a mammogram, but can't be felt or evaluated with a stereotactic biopsy. Using the mammogram as a guide, a thin wire is placed in the breast and is guided toward the lump. Wire localization is usually performed right before a surgical biopsy, and is a way to help the surgeon find the area to be removed and tested.

• Estrogen and progesterone receptor tests: If a biopsy reveals malignant cells, estrogen and progesterone receptor tests are usually performed on the malignant cells. These tests help determine whether female hormones affect the way the cancer grows. If the cancer cells have receptors for estrogen, progesterone or both, the doctor may recommend treatment with a drug tamoxifen, which prevents estrogen from binding to these sites.

• Staging: Staging breast cancer is used to help determine the course of treatment and the prognosis. Staging is based on the size of the tumor, how much of the breast tissue is cancerous, whether the underarm (axillary) lymph nodes are also cancerous, and whether cancer can be found in other parts of the body. The five-year survival rate for localized breast cancer (not spread to the axillary lymph nodes) is 96%. If cancer has spread regionally, the rate is 77%. For those women who are diagnosed with metastatic disease, the five-year survival rate is only 5 to 10%. Stage 0 cancers are also called noninvasive, or in situ (in one place) cancers. Stage I to IV cancers are invasive tumors that have the ability to spread to other areas.

Complications

• Complications of breast cancer include depression, loss of sexual interest, cachexia (physical weakness, muscle loss, and weight loss), cerebral metastases (brain), lymphangitis carcinomatosa (inflammation of the lymph vessels secondary to cancer), breast lumps, opsoclonus (uncontrolled eye movement), lung metastases, brachial plexus neuropathy (nerve damage), back pain, liver metastases, bone metastases, prostate specific antigen levels raised (plasma or serum in men), bone pain, CEA raised (marker for colon cancer), renal metastases (kidney), mastalgia (breast pain), pleural effusion (fluid around the lungs), lymphadenopathy (swelling of the lymph nodes), leucoerythroblastic anemia (blood condition), cutaneous metastasis (skin), osteosclerosis (abnormal hardness and density of the bone), and nipple discharge.

Treatment

• Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. Several experimental treatments are now offered on a limited basis or are being studied in clinical trials. Treatment for breast cancer depends on the type and stage of cancer, age, risk factors, the size and shape of the breasts, and the patient's feelings about their body.

• Treatment usually begins within a few weeks after diagnosis. Unless the cancer is detected at an extremely advanced stage and life is in immediate jeopardy, generally there is time to get a second opinion and discuss the various treatment options such as a combination of chemotherapy, radiation and surgery.

• Other factors that affect treatment decisions include lymph node status, tumor size, tumor grade, tumor type, hormone receptors, HER2/neu, proliferation rate (growth rate), metastatic tests, and oncotype diagnoses (genetics).

• A healthcare team for breast cancer patients may include surgeons, oncologists, plastic surgeons, radiation oncologists, as well as the individual's personal physician.

• Surgery: Years ago, the only type of breast cancer surgery was radical mastectomy, which removed the entire breast along with chest muscles beneath the breast and all the lymph nodes under the arm. Today, this operation is rarely performed. Instead, the majority of women are candidates for breast-saving operations such as lumpectomy. Less radical mastectomies and mastectomy with reconstruction are also options.

• Lumpectomy: This operation saves as much of the breast as possible by removing only the lump plus a surrounding area of normal tissue. Many women can have lumpectomies (often followed by radiation therapy) instead of mastectomies, and in most cases survival rates for both operations are the same. A more attractive physical appearance is also a positive with lumpectomy in contrast to a mastectomy, which removes breast tissue. However, a lumpectomy may not be an option if a tumor is deep within the breast, if the individual has already had radiation therapy, had two or more areas of cancer in the same breast that are far apart, had a connective tissue disease that makes the individual sensitive to radiation, or if they are pregnant.

• Partial or segmental mastectomy: Partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles beneath it. Some lymph nodes under the arm also may be removed. In almost all cases, a course of radiation therapy will follow the operation.

• Simple mastectomy: A simple mastectomy is the removal of all the breast tissue including the lobules, ducts, fatty tissue and a strip of skin with the nipple and areola. Depending on the results of the operation and follow-up tests, further treatment with radiation to the chest wall, chemotherapy or hormone therapy may be necessary.

• Modified radical mastectomy: A modified radical mastectomy involves the removal of the entire breast and some underarm (axillary) lymph nodes, but leaves the chest muscles intact, making breast reconstruction less complicated. Complications include severe arm swelling (lymphedema), which is a common complication of mastectomy. The lymph nodes will be tested to see if the cancer has spread.

• Sentinel lymph node biopsy: In invasive cancer, lymph nodes must be examined due to the spread of breast cancer to the lymph nodes under the arm. Surgeons used to remove as many lymph nodes as possible, greatly increasing the risk of numbness, recurrent infections, and serious swelling of the arm. A procedure was developed to detect sentinel nodes, which are the first nodes to receive the drainage from cancerous breast tumors. If a sentinel node is removed, examined and found to be healthy, the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares many women the need for a more extensive operation, and greatly decreases the risk of complications.

• Reconstructive surgery: Breast reconstruction is a possibility that most women who undergo mastectomy may choose, and a plastic surgeon will perform the procedure. Options include reconstruction with a synthetic breast implant or reconstruction using the patient's own tissue to rebuild the breast. These operations can be performed at the time of the mastectomy or at a later date. Implants may cause pain, swelling, bruising, tenderness or infection, and they do age over time requiring replacement. There is also a long-term possibility of rupture, deflation, contracture, hardening and shifting.

• Reconstruction with a tissue flap: Known as a transverse rectus abdominis myocutaneous (TRAM) flap, this surgery reconstructs the breast using tissue, including fat and muscle from the patient's abdomen. Sometimes the surgeon may also use tissue from the back or buttocks. Because the procedure is fairly complicated, recovery may take six to eight weeks, and future adjustments to the breast may be necessary. Complications include the risk of infection and tissue death. If the individual has little body fat, this type of reconstruction may not be an option.

• Deep inferior epigastric perforator (DIEP) reconstruction: In DIEP, fat tissue from the abdomen is used to create a natural-looking breast. But because the abdominal muscles are left intact, the patient is less likely to experience complications than with traditional breast reconstruction. There may also be less pain involved, and the healing time may be reduced. Active women in particular tend to opt for this procedure because it maintains the abdominal wall muscles.

• Reconstruction of the nipple and areola: After initial surgery with either tissue transfer or an implant, further surgery may be performed to create a nipple and areola. Using tissue from elsewhere in the body, the surgeon first creates a small mound to resemble a nipple. The surgeon may then tattoo the skin around the nipple to create an areola. The surgeon may also take a skin graft from elsewhere on the body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.

• Radiation therapy: Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. Radiation is administered by a radiation oncologist or technician at a radiation center. In general, radiation is the standard of care following a lumpectomy for both invasive and noninvasive breast cancers. Oncologists are also likely to recommend radiation following a mastectomy for a large tumor that has spread to more than four lymph nodes in the armpit.

• Radiation is usually started three to four weeks after surgery. The patient will typically receive treatment five days a week for five to six consecutive weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes, and side effects include fatigue, nausea, vomiting, weight loss, and loss of appetite.

• In a small percentage of women, more serious problems may occur, including arm swelling, damage to the lungs, heart or nerves, or a change in the appearance and consistency of breast tissue. Radiation therapy may also make it somewhat more likely that an individual will develop another tumor.

• Chemotherapy: Chemotherapy uses drugs to destroy cancer cells and is given by mouth or into the veins. Chemotherapy for breast cancer may be used to cure the cancer, stop cancer from spreading to other parts of the body, slow cancer growth, kill cancer cells, and relieve the symptoms of breast cancer. Breast cancer patients who undergo chemotherapy may be given one drug or a combination of two or more drugs during treatment. A chemotherapy regimen is usually tailored specifically to the breast cancer patient. In general, chemotherapy for breast cancer patients is typically given in three to six month courses. These courses may occur daily, weekly, monthly or on some other schedule, depending on the body's response to the drugs. Chemotherapy sessions are not usually continuous, typically including rest cycles because chemotherapy drugs target both healthy and cancerous cells. Physicians have a variety of ways to monitor the effects of chemotherapy on the patient's cancer, including physical examinations, blood tests, CT scans, MRI scans, and x-rays.

• For many women, chemotherapy causes unwanted side effects including hair loss, nausea, vomiting, and fatigue. Another side effect called "chemobrain" may occur. Chemobrain is the term for cognitive changes that occur during and after cancer treatment. Women undergoing adjuvant chemotherapy may have trouble finding words, a poor memory, decreased learning, processing speed, and ability to multitask. Up to one-third of people undergoing cancer treatment will experience cognitive impairment, though some studies report that at least half the participants have memory problems. Memory changes often continue for at least a year or two after treatment and may last longer.

• Premature menopause and infertility also are potential side effects of chemotherapy. The older the individual is when treatment begins, the more likely they are to develop menopausal problems.

• Commonly used chemotherapy drugs include CMF therapy that consists of cyclophosphamide (Cytoxan®), methotrexate (Mexate®, Folex®), and fluorouracil (Fluorouracil®, 5-Fu, Adrucil®). CAF therapy consists of cyclophosphamide, doxorubicin (Adriamycin®), and fluorouracil. AC therapy includes doxorubicin (Adriamycin®) and cyclophosphamide. Other combinations include doxorubicin (Adriamycin®) and cyclophosphamide with paclitaxel (Taxol®), doxorubicin (Adriamycin®), followed by CMF, and cyclophosphamide, epirubicin (Ellence®), and fluorouracil. Other chemotherapy drugs commonly used for treating women with breast cancer include docetaxel (Taxotere®), vinorelbine (Navelbine®), and gemcitabine (Gemzar®), and capecitabine (Xeloda®). Ixabepilone (Ixempra®) was approved by the U.S. Food and Drug Administration in October 2007 for use in patients with metastatic or locally advanced breast cancer who have not responded to certain other cancer drugs.

• Abraxane® (paclitaxel protein-bound particles for injectable suspension): Abraxane® was approved by the U.S. Food and Drug Administration (FDA) in 2005 to help treat women with advanced breast cancer who have not responded well to combination chemotherapy, or who have relapsed within six months of chemotherapy. Abraxane® is similar to the drug Taxol® but it is not required to be dissolved in a toxic solvent prior to administration. This solvent can cause allergic reactions in some patients, and to counteract these reactions patients are often treated with steroids and antihistamines. Patients receiving Abraxane® do not need these pre-medications. Side effects of Abraxane® may include neutropenia (a reduction in white blood cell count), anemia (a decreased number of red blood cells and a reduced volume of hemoglobin, the protein within red blood cells that carries oxygen), infections, edema (swelling), nausea, vomiting, diarrhea, nerve damage, and severe pain in the muscles or joints.

• Adriamycin® (doxorubicin): Adriamycin® is a chemotherapy drug commonly used to treat breast cancer and other cancers. Adriamycin® first disrupts, and then destroys the growth of cancer cells. It is usually administered intravenously (through the vein). Common side effects may include decreased white blood cell count with increased risk of infection, decreased platelet count with increased risk of bleeding, loss of appetite, darkening of nail beds and skin creases of hands, hair loss, nausea and vomiting, and mouth sores. Patients should be tested for heart problems before beginning Adriamycin® and should be continuously monitored for developing problems during treatment.

• Aredia® (pamidronate disodium): Breast cancer has the potential to spread to almost any area of the body. After the axillary (armpit) lymph nodes, bone is the most common place to which breast cancer can spread. Aredia® reduces bone complications and bone pain in patients whose breast cancer has spread to the bone. Clinical studies have shown that patients who are given Aredia® tend to experience a delay in or reduction of bone pain, fractures, and other bone complications than patients who do not receive Aredia®. Aredia® is usually administered by intravenous injection. Possible side effects include fever, fatigue, nausea and vomiting, initial bone pain, lack of appetite, and anemia (decrease in red blood cells).

• Arimidex® (anastrozole): Arimidex® was FDA approved in 1996 to treat advanced (metastatic) breast cancer in patients who have not responded well to treatment with the drug tamoxifen. Clinical trials are currently underway to determine whether women with advanced breast cancer would benefit more from taking Arimidex® than tamoxifen. Arimidex® is usually taken orally, and possible side effects include general feelings of weakness, decreased energy levels, headache, nausea, mild diarrhea, increased or decreased appetite, sweating, hot flashes, vaginal dryness, and temporary hair thinning.

• Aromasin (exemestane): Aromasin® (exemestane) was FDA approved in 1999 to treat advanced (metastatic) breast cancer in post-menopausal women. Aromasin® works by binding to the body's aromastase enzyme, an enzyme responsible for producing the hormone estrogen. Many breast cancer cells depend on estrogen to grow and multiply quickly. Once Aromasin® has binded to the aromastase enzyme, estrogen cannot be produced by the enzyme. This lack of estrogen "starves" cancer cells preventing them from growing. Aromasin® is usually taken orally, and possible side effects include hot flashes, nausea, fatigue, increased sweating, and increased appetite.

• Cytoxan® (cyclophosphamide): Cytoxan® (cyclophosphamide) is a chemotherapy drug commonly used to treat breast cancer and other cancers. Cytoxan® first disrupts cancer cells and then destroys them. Cytoxan® is given by mouth or intravenously (through the vein) over 30-60 minutes. Common side effects may include decreased white blood cell count with increased risk of infection, hair loss, nausea and vomiting, loss of appetite, sores in mouth or on lips, diarrhea, and ceasing of menstrual periods.

• Ellence® (epirubicin): Ellence® was approved by the FDA in 1999 to treat early-stage breast cancer after breast surgery (lumpectomy or mastectomy) in patients whose cancer has spread to the axillary (underarm) lymph nodes. Ellence® helps reduce the likelihood that breast cancer will return, and improves a patient's chances of survival. Ellence® is given intravenously (through the vein) in combination with other chemotherapy drugs, such as cyclophosphamide and fluorouracil. Possible side effects include nausea, vomiting, diarrhea, inflammation of the mouth (stomatitis), hair loss, and reduction in white blood cells (myelosuppression).

• Fareston® (toremifene): Similar to tamoxifen, Fareston® is an anti-estrogen (SERM, selective estrogen-receptor modulator). Fareston® binds to estrogen receptors on breast cancer cells preventing them from growing and dividing. Advanced breast cancer patients are usually prescribed one 60 milligram tablet of Fareston® daily. Possible side effects include hot flashes, nausea, weight gain, allergic reactions (such as skin rashes), and headache.

• Femara® (letrozole): Femara® was approved by the FDA in 1997 to help treat advanced (metastatic) breast cancer in women whose breast cancer tumors have not responded well to tamoxifen. Femara® works by reducing the total amount of estrogen in the body (circulating estrogen levels), thereby limiting the amount of estrogen that can affect breast cancer cells. In post-menopausal women, the body produces estrogen from other hormones known as androgens by an enzyme called aromatase. Femara® is an aromatase inhibitor and blocks aromatase from converting androgen into estrogen, thus lowering the amount of estrogen in the body. Possible side effects may include musculoskeletal pain (pain in the skeleton or legs, arms or back), nausea, headache, joint pain, fatigue, and difficulty breathing.

• Herceptin® (trastuzumab): Herceptin® is FDA approved to treat advanced metastatic breast cancer in women who over-express the HER2 gene. HER2 (also written HER-2/neu) is a growth factor found on the surface of cells that plays a key role in regulating cell growth. Some women are born with or experience a mutation of the HER2 gene throughout their lifetime. When altered, extra HER2 receptors may be produced. This over-expression of HER2 causes cells to grow, divide, and multiply more rapidly than normal , which can lead to breast cancer. Women who over-express the HER2 gene tend to have aggressive breast cancers that spread quickly to other regions of the body. Herceptin® seeks out HER2 and attaches itself to the protein receptor on the surface of cells. By binding to the cells, Herceptin® has been reported to slow the growth and spread of tumors that have an overabundance of HER2 protein receptors. Herceptin® is usually given intravenously in an outpatient clinical setting. Possible side effects include weakening of the heart muscle, reduction of white blood cells (leukopenia or neutropenia), diarrhea, anemia, and abdominal pain or infection.

• Megace® (megestrol): Megace® is used to treat advanced breast cancer, typically in women who do not respond well or become resistant to tamoxifen. Megace® is a synthetic form of the hormone progesterone. Progesterone is normally secreted by the corpus luteum of the ovary and placenta, and then acts to prepare the uterus for implantation of the fertilized ovum, to maintain pregnancy, and to promote development of secondary sexual characteristics. Progesterone also counteracts some of the negative effects of estrogen (many breast cancers depend on estrogen to grow and reproduce). Because Megace® is considered non-toxic, there are few documented side effects associated with the drug. The most common side effect is fluid retention.

• Nolvadex® (tamoxifen): Tamoxifen has been the most commonly prescribed drug to treat breast cancer since its approval by the U.S. Food and Drug Administration (FDA) in the 1970s. Tamoxifen is an anti-estrogen and works by competing with the hormone estrogen by binding to estrogen receptors in breast cancer cells. By blocking estrogen in the breast, tamoxifen helps slow the growth and reproduction of breast cancer cells. In 1998, tamoxifen became the first drug to be approved by the FDA to prevent breast cancer after research showed it reduced the chances of developing breast cancer by 50% in high risk women. Tamoxifen is taken orally, and possible side effects include hot flashes, irregular menstrual cycles, unusual vaginal discharge or bleeding, and irritation of skin around the vagina.

• Taxol® (paclitaxel): Taxol® was isolated from a Pacific yew tree and first approved by the FDA in 1992 to treat advanced (metastatic) breast cancer. In 1999, the FDA also approved Taxol® to treat early stage breast cancer in patients who have previously received chemotherapy with the drug doxorubicin. Taxol® is called a mitotic inhibitor because it interferes with cells during mitosis (cell division). Taxol® is usually given intravenously over one or more hours. Possible side effects include a reduced white blood cell count (myelosuppression), hair loss (alopecia), and numbness in the extremities (peripheral neuropathy).

• Taxotere® (docetaxel): Taxotere® (generic name, docetaxel) is a cancer drug that resembles Taxol® in chemical structure. Taxotere® was FDA approved in 1996 to treat advanced breast cancer in patients who have not responded well to chemotherapy with the drug doxorubicin. In 1998, it was also approved by the FDA to treat breast cancer that has spread into other areas of the breast or to other parts of the body after treatment with standard chemotherapy. Docetaxel inhibits the division of breast cancer cells by acting on the cell's internal skeleton. The drug is usually given intravenously (through the vein) once every three weeks. Each treatment typically takes around one hour, though the dosage will vary depending on the patient's medical situation. Other medications may be used to counter the side effects of Taxotere®; for example, dexamethasone is commonly used to prevent fluid retention. Other possible side effects include decrease in white blood cells (leukopenia), fever (often a warning sign of infection), fluid retention, allergic reactions, and hair loss.

• Xeloda® (capecitabine): Xeloda® has been FDA approved since April 1998 as a treatment for advanced breast cancer in patients who have not responded well to chemotherapy that included Taxol® and Adriamycin®. Xeloda works by converting to a substance called 5-fluorouracil in the body. In some patients, Xeloda helped shrink tumor size by killing cancer cells. Side effects may include diarrhea, nausea and vomiting, stomatitis (sores in mouth and throat), loss of appetite or decreased appetite, and excessive water loss from the body (dehydration). Some of the side effects from Xeloda® may become severe. Patients should report any side effects to their physicians immediately. Xeloda® is taken orally and is usually prescribed in a 21-day cycle (14 days of treatment followed by a seven-day rest period).

• Zoladex® (goserelin acetate): Zoladex® is FDA approved to treat advanced breast cancer and prostate cancer. Zoladex® works by blocking estrogen from breast cancer cells (and blocking testosterone in men) thereby starving these cells. The drug is typically given by injection under the skin (subcutaneously). Zoladex® is a systemic treatment and cannot distinguish between normal cells and cancer cells; therefore, a variety of side effects are possible, including hot flashes, decreased sexual desire, absence of menstruation, vaginal dryness, and breast swelling or tenderness.

• Zometa® (zoledronic acid): Zometa® was approved by the FDA in 2002 to treat breast cancer that has spread to the bone (a condition commonly referred to as bone metastases). Zometa® is also FDA-approved to treat multiple myeloma (a type of bone cancer), all other solid tumors, and bone metastases resulting from prostate cancer. Zometa® belongs to a class of drugs called bisphosponates, which may be helpful in bone metastases by slowing the destruction of bone cells in breast cancer patients. Zometa® may also prevent cancer cells from growing in bone. Studies involving more than 3,000 patients taking zometa® have shown an approximate 14% decrease in the number of patients with bone problems, compared to those who did not take Zometa®. Zometa® is administered intravenously and takes approximately 15 minutes after preparation. Possible side effects include pain nausea and vomiting, fever, fatigue, and constipation. Women who are pregnant or breastfeeding should avoid zometa®. In rare cases, Zometa® can cause injury to the kidneys.

• Medications for side effects of chemotherapy: Some patients who experience certain side effects of chemotherapy may be prescribed medications to counteract these effects. Several drugs are now available for use alone or in combination to help reduce a few of the most common side effects, such as nausea, vomiting, and fatigue.

• Anzemet (dolasetron mesylate): Anzemet® helps prevent and relieve nausea and vomiting from surgery or chemotherapy. Researchers believe that nausea and vomiting during chemotherapy is associated with the release of serotonin from special cells in the small intestine. Anzemet® blocks these nerve endings in the intestine and prevents signals to the central nervous system. Anzemet® is available in tablet form and by injection.

• Compazine® (prochlorperazine): Prochlorperazine helps control nausea and vomiting after surgery or chemotherapy. Prochlorperazine is available in capsule, tablet, and liquid form, and by suppository or injection. Prochlorperazine can cause drowsiness and may interact with other medications or alcohol.

• Kytril® (granisetron hydrochloride): Kytril® is an anti-nausea medication FDA approved for patients undergoing chemotherapy. Kytril® is typically given 60 minutes before chemotherapy. In some cases, a second dose is given about 12 hours after the first dose. Kytril® is available in tablet form and by injection.

• Phenergan® (promethazine): Promethazine has sedative, antihistamine, and mild anti-nausea properties. It may be used to help prevent or treat nausea due to chemotherapy. Promethazine may be available in tablet form or as an oral syrup, suppository or injection.

• Procrit® (epoetin alfa): Procrit® helps the body produce more red blood cells, which helps relieve fatigue due to chemotherapy. Since chemotherapy affects both normal and cancerous cells, it can decrease the number of red blood cells, which leads to anemia (feeling of extreme tiredness).

• Zofran® (ondansetron): Zofran® helps to relieve nausea and vomiting associated with chemotherapy. Zofran® is available in pill form, as a liquid solution, and by injection. The first dose of Zofran® (tablet form) is usually administered 30 minutes before chemotherapy and then at regular intervals for one to two days after chemotherapy.

• Patients who experience low blood cells counts during chemotherapy may also be given medications to help raise blood cell or platelet counts. For example, patients who suffer from neutropenia, a decrease in the number of neutrophils (a type of white blood cell), may be given certain growth factors, such as the granulocyte-macrophage colony stimulating factor (GM-CSF, sargramostim, or Leukine®) or granulocyte colony stimulating factor (G-CSF, filgrastim, or Neupogen®).

• High-dose chemotherapy: High-dose chemotherapy with stem cell transplant is a way of giving high doses of chemotherapy and replacing blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These re-infused stem cells grow into (and restore) the body's blood cells. Studies have reported that high-dose chemotherapy followed by stem cell transplant does not work better than standard chemotherapy in the treatment of breast cancer.

• New clinical trials: A number of new approaches to treating cancer are being studied, with an emphasis on methods that can successfully treat women or extend their survival with minimal side effects. Among these are drugs that block the biochemical switches that cause normal cells to turn cancerous. A procedure known as anti-angiogenesis, which targets the blood vessels that supply nutrients to cancer cells, is also being studied. Nonsurgical methods being studied to remove breast tissue include techniques that use heat or cold to kill cancer cells deep within the breast, leaving only minimal scars.

• Ductal Carcinoma in situ (DCIS): Treatment of DCIS may include breast-conserving surgery with or without radiation or hormone therapy, and total mastectomy with or without hormone therapy.

• Lobular Carcinoma in situ (LCIS): Treatment of LCIS may include biopsy to diagnose LCIS followed by regular examinations and regular mammograms to find any changes as early as possible. Tamoxifen may be used to reduce the risk of developing breast cancer. Bilateral prophylactic mastectomy is a treatment choice sometimes used in women who have a high risk of getting breast cancer.

• Stage I, Stage II, Stage IIIA, and Operable Stage IIIC Breast Cancer: Treatment of stage I, stage II, stage IIIA, and operable stage IIIC breast cancer may include breast-conserving therapy to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy or a modified radical mastectomy with or without breast reconstructive surgery. Adjuvant therapy (treatment given after surgery to increase the chances of a cure) may include radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy, systemic chemotherapy with or without hormone therapy, hormone therapy, and the monoclonal antibody Herceptin® combined with systemic chemotherapy.

• Stage IIIB and inoperable stage IIIC breast cancer: Treatment of these categories of breast cancer may include systemic chemotherapy, systemic chemotherapy followed by surgery (breast conserving therapy or total mastectomy) with lymph node dissection followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given.

• Stage IV and metastatic breast cancer: Treatment of stage IV or metastatic breast cancer may include hormone therapy and/or systemic chemotherapy with or without trastuzumab (Herceptin®), radiation therapy and/or surgery for relief of pain and other symptoms, and new high-dose chemotherapy with stem cell transplants are being tested in clinical trials. Bisphosphonate drugs can be given to reduce bone disease and pain when cancer has spread to the bone.

• Inflammatory breast cancer (IBC): Treatment of inflammatory breast cancer may include systemic chemotherapy, systemic chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), lymph node dissection, followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given. Monoclonal antibody therapy including lapatinib (Tykerb®) and trastuzumab (Herceptin®) may be given.

• Recurrent breast cancer: Treatment of recurrent breast cancer (cancer that has come back after treatment) in the breast or chest wall may include surgery (radical or modified radical mastectomy), radiation therapy, or both, systemic chemotherapy or hormone therapy, and clinical trials of trastuzumab (Herceptin®) combined with systemic chemotherapy are currently being done.

• Menwith breast cancer: More than 1,000 men in the United States are diagnosed with breast cancer every year. While men are 150 times less likely to develop breast cancer than women, male breast cancer should not be ignored. Usually, the first sign is a lump in the breast, which tends to be misdiagnosed. In general, men are diagnosed at a later stage of the disease; however, when matched against women with the same stage and age, the prognosis for men is the same. Any mass in the breast of a man should be thoroughly examined. The risk for developing breast cancer is higher for men with enlargement of the breast tissue (gynecomastia). A modified radical mastectomy is the usual course of treatment for men. Radiation may also be given. Almost 90% of men with breast cancer have the type of tumors that respond to hormone therapy.

• Male breast cancer is similar to female breast cancer in that the information on symptoms, diagnosis, treatment, and living with the disease is the same. Men, however, do not need routine screening.

• Follow-up: Follow-up will require frequent medical visits, often every three to four months for the first five years after the initial diagnosis. Follow-up visits should focus on determining whether cancer has appeared in the opposite breast, in the same breast, or in areas other than the breasts. In general, signs and symptoms often lead to the diagnosis of a recurrence. It is important to inform the physician about any changes in health such as coughing, dizziness, headaches, or pain no matter how minor they seem.

• Prognosis: Thirty percent of patients without node involvement and 75% of patients with node involvement at diagnosis will develop metastatic disease (cancer that has spread to other tissues). Metastatic disease generally develops within five years after the initial diagnosis, although it can occur as many as 10 or more years later. Metastatic disease (Stage IV) is incurable, and the five-year survival rate is about 5 to 10%.

Integrative Therapies

• Good scientific evidence:

• Greater celandine: Ukrain™, a semisynthetic drug derived from greater celandine (Chelidonium majus), has been studied in clinical trials of various types of cancer with consistently positive outcomes. However, the quality of the research performed to date is inadequate, and higher quality studies are needed.

• Use cautiously in patients taking amphetamines, morphine, hexobarbital, MAOIs, or dopaminergic or serotonergic drugs, or in patients undergoing radiation therapy. Avoid in patients with liver disease or in pregnant and lactating women.

• Guided imagery: Early research suggests that guided imagery may help reduce cancer pain. Further research is needed to confirm these results.

• Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified health care provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety or emotional upset because imagery may trigger these symptoms. If feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse, speak with a qualified health care provider before practicing guided imagery.

• Meditation: There is good evidence that various types of meditation may help improve quality of life in cancer patients. Studies have shown benefits for mood, sleep quality, and the stresses of treatment. The specific effects of meditation are not fully understood. Additional research is needed in this area.

• Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

• Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health care professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). There is good evidence that psychotherapy may enhance quality of life in cancer patients by reducing emotional distress and aiding in coping with the stresses and challenges of cancer. Therapy may be supportive-expressive therapy, cognitive therapy or group therapy. While some patients seek psychotherapy in hopes of extending survival, there conclusive evidence of effects on medical prognosis is currently lacking. Psychotherapy may help people come to terms with the fact that they may die of cancer, which is the 4th stage of dealing with a terminal illness, including denial, anger, bargaining, and acceptance.

• Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.

• Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Several studies report enhanced quality of life in cancer, lower sleep disturbance, decreased stress symptoms and changes in cancer-related immune cells after patients received relaxation, meditation and gentle yoga therapy. Yoga is not recommended as a sole treatment for cancer but may be helpful as an adjunct therapy.

• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

• Unclear or conflicting scientific evidence:

• Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. There has been limited research on acupuncture for cancer pain, and the research that was done was shown to have mixed results. More studies are needed to determine potential benefits. Evidence from several small studies supports use of acupuncture at a specific point on the wrist (P6) to help chemotherapy patients reduce nausea and vomiting. Acupuncture may also reduce the pain associated with cancer.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

• Aloe: Transparent gel from the pulp of the meaty leaves of Aloe vera has been used on the skin for thousands of years to treat wounds, skin infections, burns, and numerous other skin conditions. Dried latex from the inner lining of the leaf has traditionally been used as an oral laxative. Preliminary research suggests that aloe may help in the area of cancer prevention or may aid in the regression of cancerous tumors. Additional research is needed in this area.

• Caution is advised when taking aloe supplements as numerous adverse effects including a laxative effect, cramping, dehydration and drug interactions are possible. Aloe should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• American pawpaw: Evidence supporting the use of the American pawpaw (Asimina triloba) tree for cancer treatment in humans is largely anecdotal and subjective. However, use in humans has reported minimal side effects, and evidence from animal and test tube studies suggest that American pawpaw extract does have some anticancer activity. Pawpaw standardized extract has been used for 18 months in patients with various forms of cancer. Well-designed studies on the long-term effects of pawpaw extracts are currently lacking. Pawpaw should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Antineoplastons: Antineoplastons are a group of naturally occurring peptide fractions, which were observed by Stanislaw Burzynski, MD, PhD in the late 1970s to be absent in the urine of cancer patients. There is inconclusive scientific evidence regarding the effectiveness of antineoplastons in the treatment of cancer. Several preliminary human studies (case series, phase I/II trials) have examined antineoplaston types A2, A5, A10, AS2-1, and AS2-5 for a variety of cancer types. It remains unclear if antineoplastons are effective, or what doses may be safe. Until better research is available, no clear conclusion can be drawn.

• Avoid if allergic or hypersensitive to antineoplastons. Use cautiously with high medical or psychiatric risk, an active infection due to a possible decrease in white blood cells, high blood pressure, heart conditions, chronic obstructive pulmonary disease, liver disease or damage, or kidney disease or damage. Avoid if pregnant or breastfeeding.

• Arabinoxylan: Arabinoxylan is made by altering the outer shell of rice bran using enzymes from Hyphomycetes mycelia mushroom extract. Arabinoxylan has been found to improve immune reactions in patients with diabetes and cancer of various types. Arabinoxylan products may contain high calcium and phosphorus levels, which may be harmful for patients with compromised renal (kidney) function. Caution is advised when taking arabinoxylan supplements, as numerous adverse effects including drug interactions are possible. Arabinoxylan should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Arginine: It is unclear if arginine can help treat breast cancer patients. Results from early human studies are mixed. High-quality studies are needed. Avoid if allergic to arginine, if you have history of stroke, liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

• Aromatherapy: Healing with fragrant oils has been used for thousands of years. Aromatherapy is often used in people with chronic illnesses (frequently in combination with massage), with the intention to improve quality of life or well-being. There is currently not enough scientific evidence to form a firm conclusion about the effectiveness of aromatherapy for quality of life in cancer.

• Essential oils should only be used on the skin in areas without irritation. Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving or operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.

• Art therapy: Art therapy involves the application of a variety of art modalities including drawing, painting, clay and sculpture. Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. Limited evidence suggests that art therapy may be of benefit in cancer caregiving for families of cancer patients. Possible benefits include reduced stress, lowered anxiety, increased positive emotions and increased positive communication with cancer patients and health care professionals. Art therapy may also reduce pain and other symptoms in cancer patients. More studies are needed to determine how best to use this form of intervention with this population. Art therapy may also benefit children hospitalized with leukemia during and after painful procedures. Limited available study suggests that art therapy improves cooperation with treatment. Children requested art therapy again when procedures were repeated, and parents reported that children were more manageable after art therapy.

• Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.

• Astragalus: Astragalus (Astragalus membranaceus) has been used in Chinese medicine for centuries for its immune enhancing properties. Although early laboratory and animal studies report immune stimulation and reduced cancer cell growth associated with the use of astragalus, reliable human evidence in these areas is currently lacking. In Chinese medicine, astragalus-containing herbal mixtures are also sometimes used with the intention to reduce side effects of chemotherapy and other cancer treatments. Astragalus-containing herbal combination formulas may also have beneficial effects in aplastic anemia. Due to a lack of well-designed research, a firm conclusion cannot be drawn.

• Caution is advised when taking astragalus supplements, as numerous adverse effects including drug interactions are possible. Astragalus should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Baikal skullcap: Although the outcomes of early studies using baikal skullcap for cancer are promising, high-quality clinical studies are needed in this area before a conclusion can be made. Avoid if allergic or hypersensitive to Baikal skullcap (Scutellaria barbata), its constituents, or members of the Lamiaceae family. Use cautiously if taking sedatives and/or operating heavy machinery. Use cautiously if taking antineoplastic (anticancer) agents or agents metabolized by cytochrome P450 enzymes. Avoid if pregnant or breastfeeding. Baikal skullcap is an ingredient in PC-SPES, a product that has been recalled from the U.S. market and should not be used.

• Bee pollen: Bee pollen is considered a highly nutritious food because it contains a balance of vitamins, minerals, proteins, carbohydrates, fats, enzymes, and essential amino acids. Research has found that bee pollen may reduce some adverse effects of cancer treatment side effects. Additional study is needed before a firm recommendation can be made. Caution is advised when taking bee pollen supplements as allergic reactions may occur in sensitive individuals. Bee pollen should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Beta-glucan: Treatment with a beta-glucan, called lentinan, plus chemotherapy (S-1) may help prolong the lives of patients with cancer that has returned or cannot be operated on. More research is needed in this area. Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucan is generally considered safe. Use cautiously with AIDS or AIDS-related complex (ARC). Avoid using particulate beta-glucan. Avoid if pregnant or breastfeeding.

• Bitter melon: Bitter melon (Momordica charantia) is used in Avurvedic medicine from India to lower blood sugar levels. Research has also found that bitter melon extracts may be beneficial in cancer therapies. MAP30, a protein isolated from bitter melon extract, is reported to possess anti-cancer effects in laboratory studies. Potential anti-cancer effects have not been studied appropriately in humans. Caution is advised when taking bitter melon supplements, as numerous adverse effects including blood sugar lowering and drug interactions are possible. Bitter melon should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Black cohosh: Black cohosh (Actaea racemosa) is used for pre- and postmenopausal symptoms such as hot flashes and irritability. Recent study found that the use of black cohosh had a significant protective effect for breast cancer. Additional confirmatory studies are required.

• Caution is advised when taking black cohosh supplements, as numerous adverse effects including drug interactions are possible. Black cohosh should not be used if pregnant or breastfeeding unless otherwise directed by a doctor.

• Black tea: Black tea (Camellia sinensis) is from the same plant as green tea, but the leaves are processed differently. Black tea usually contains more caffeine than green tea. Several studies have explored a possible association between regular consumption of black tea and rates of cancer in several populations. This research has yielded conflicting results, with some studies suggesting benefits, and others reporting no effects. Laboratory and animal studies report that components of tea, such as polyphenols, have antioxidant properties and effects against tumors. However, effects in humans remain unclear, and these components may be more common in green tea rather than in black tea. Some animal and laboratory research suggests that components of black tea may actually be carcinogenic, or cancer causing, although effects in humans are not clear. Overall, the relationship of black tea consumption and human cancer prevention remains undetermined.

• Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use cautiously if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances/insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.

• Bovine cartilage: In early study, bovine tracheal cartilage (preparations such as Catrix® and VitaCarte®) has been studied for the treatment of cancer with encouraging results. High quality clinical research is needed to better determine the effectiveness of bovine tracheal cartilage preparations for cancer treatment.

• Avoid if allergic or hypersensitive to bovine cartilage or any of its constituents. Use cautiously with cancer, renal (kidney) failure, or hepatic (liver) failure. Avoid if pregnant or breastfeeding.

• Bromelain: Bromelain is a sulfur-containing digestive enzyme (proteins which help with digestion) that is extracted from the stem and the fruit of the pineapple plant (Ananas comosus). There is not enough information to recommend for or against the use of bromelain in the treatment of cancer, either alone or in addition to other therapies. One small study found that a bromelain supplement decreased tumor size in 12 breast cancer patients. Patients took the supplements for different periods of time, lasting from months to years. Caution is advised when taking bromelain supplements, as numerous adverse effects including blood thinning and drug interactions are possible. Bromelain should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Cat's claw: Originally found in Peru, the use of cat's claw (Uncaria tomentosa) has been said to date back to the Inca civilization, possibly as far back as 2,000 years. Cat's claw has anti-inflammatory properties, and several low-quality studies suggest that cat's claw may slow tumor growth. However, this research is early and has not identified specific types of cancer that may benefit; thus, the results are not clear. A few studies suggest that cat's claw may also boost the immune system. Caution is advised when taking cat's claw supplements, as numerous adverse effects including blood thinning and drug interactions are possible. Cat's claw should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Chaparral: Chaparral was used by the Native Americans for various health conditions. The chaparral component nordihydroguaiaretic acid (NDGA) has been evaluated as a treatment for cancer but due to risk of toxicity is considered unsafe and not recommended for use. Chaparral and NDGA have been associated with cases of kidney and liver failure, liver cirrhosis, kidney cysts, and kidney cancer in humans. In response to these reports, the U.S. Food and Drug Administration (FDA) removed chaparral from its "generally recognized as safe" (GRAS) list in 1970. Chaparral and NDGA are generally considered unsafe and are not recommended for use.

• Avoid if allergic to chaparral or any of its components, including nordihydroguaiaretic acid. Use cautiously if taking blood thinners (anticoagulants), blood sugar medication, or drugs that are broken down by the liver (like amiodarone, phenobarbital, valproic acid). Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if pregnant or breastfeeding.

• Chlorophyll: Preliminary evidence in suggest that chlorophyll may aid in the reduction of side effects associated with photodynamic therapies, such as those used in management of malignant tumors. Further research is required to support the use of chlorophyll as a laser therapy adjunct for cancer treatment.

• Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or antidiabetes agents. Avoid if pregnant or breastfeeding.

• Chrysanthemum: Early study indicates that hua-sheng-ping (includes Chrysanthemum morifolium, Glycyrrhiza uralensis, and Panax notoginseng) may be beneficial for patients with precancerous lesions. However, more research is needed.

• Avoid if allergic or hypersensitive to Chrysanthemum, its constituents, or members of the Asteraceae/Compositae family, such as dandelion, goldenrod, ragweed, sunflower, and daisies. Use cautiously if taking medication for gout, cancer, or HIV. Use cautiously with compromised immune systems or if taking immunomodulators. Avoid with photosensitivity or if taking photosensitizers. Avoid large acute or chronic doses of ingested pyrethrin. Avoid pyrethrin with compromised liver function, epilepsy, or asthma. Avoid ocular exposure to pyrethrin. Avoid if pregnant or breastfeeding.

• Coenzyme Q10: Further research is needed to determine if coenzyme Q10 (CoQ10) may be of benefit for cancer when used with other therapies. Although supplementation of CoQ10 has been reported to improve general health, it has not been proven to reduce cancer, and it has not been compared to other forms of breast cancer treatment. Although its use is not clearly defined, CoQ10 levels are generally decreased in breast cancer patients; therefore, further testing needs to be done.

• Allergy associated with Coenzyme Q10 supplements has not been reported, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix®), or blood pressure, blood sugar, cholesterol or thyroid drugs. Avoid if pregnant or breastfeeding.

• Copper: Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains and fruits, as well as shellfish, avocado, and beef (organs such as liver). Preliminary research reports that lowering copper levels theoretically may arrest the progression of cancer by inhibiting blood vessel growth (angiogenesis). Copper intake has not been identified as a risk factor for the development or progression of cancer. Copper is potentially unsafe when used orally in higher doses than the RDA. Copper supplements should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Cranberry: Several laboratory studies have reported positive effects of proanthocyanidins, flavonoid components of cranberry (Vaccinium macrocarpon) and other fruits such as blueberries, grape seed, and pomegranate, on health. Based on early laboratory research, cranberry has been proposed for cancer prevention. Additional study is needed in humans before a conclusion can be made.

• Avoid if allergic to cranberries, blueberries or other plants of the Vaccinium species. Sweetened cranberry juice may effect blood sugar levels. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.

• Dandelion: Limited animal research does not provide a clear assessment of the effects of dandelion on tumor growth. Well-conducted human studies are needed to better determine dandelion's effects on cancer.

• Avoid if allergic to chamomile, feverfew, honey, yarrow, or any related plants such as aster, daisies, sunflower, chrysanthemum, mugwort, ragweed, or ragwort. Use cautiously with diabetes or bleeding disorders, gastroesophageal reflux disease (GERD), kidney or liver diseases, or a history of stroke or electrolyte disorders. Monitor potassium blood levels. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

• Echinacea: There is currently a lack of clear human evidence that echinacea affects any type of cancer. The evidence from a small number of clinical trials evaluating efficacy of echinacea in the treatment of radiation-induced leukopenia (decrease in white blood cells) is equivocal. Studies have used the combination product Esberitox®, which includes extracts of echinacea (Echinacea purpurea and pallida) root, white cedar (Thuja occidentalis) leaf, and wild indigo (Baptisia tinctoria)root. Additional clinical studies are needed to make a conclusion.

• Caution is advised when taking echinacea supplements, as numerous adverse effects including drug interactions are possible. Echinacea should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Essiac®: Essiac® contains a combination of herbs, including burdock root (Arctium lappa), sheep sorrel (Rumex acetosella), slippery elm inner bark (Ulmus fulva), and Turkish rhubarb (Rheum palmatum). The original formula was developed by the Canadian nurse Rene Caisse (1888-1978) and is thought to be effective in cancer therapies, although currently there is not enough evidence to recommend for or against the use of this herbal mixture as a therapy for any type of cancer. Different brands may contain variable ingredients, and the comparative effectiveness of these formulas is not known. None of the individual herbs used in Essiac® has been tested in rigorous human cancer trials, although some components have anti-tumor activity in laboratory studies. Numerous individual patient testimonials and reports from manufacturers are available on the Internet, although these cannot be considered scientifically viable as evidence. Individuals with cancer are advised not to delay treatment with more proven therapies. Caution is advised when taking Essiac® supplements, as numerous adverse effects including drug interactions are possible. Essiac® should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Evening primrose oil: Not enough information is available to advise the use of evening primrose oil for breast cancer. People with known or suspected breast cancer should consult with a qualified healthcare professional about possible treatments.

• Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

• Flaxseed: There is a lack of information from human studies indicating that flaxseed (not flaxseed oil) is effective in preventing or treating breast cancer.

• Flaxseed has been well-tolerated in studies for up to four months. Use cautiously with a history of a bleeding disorder or with drugs that increase bleeding risk (like anticoagulants and non-steroidal anti-inflammatories (like aspirin, warfarin, Advil®)), high triglyceride levels, diabetes, mania, seizures, or asthma. Avoid if allergic to flaxseed, flaxseed oil or other plants of the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed with a history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid with a history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Avoid topical flaxseed in open wounds or abraded skin surfaces. Avoid if pregnant or breastfeeding. Avoid with prostate cancer, breast cancer, uterine cancer or endometriosis. Avoid ingestion of immature flaxseed pods.

• Focusing: Focusing (experiential therapy) is a method of psychotherapy that involves being aware of one's feelings surrounding a particular issue and understanding the meaning behind words or images conveyed by those feelings. Early evidence suggests focusing may improve mood and attitude in cancer patients. Firm recommendations cannot be made until well-designed clinical trials are available.

• Side effect reporting is rare, but patients should consult with a qualified healthcare practitioner before making decisions about medical conditions and practices. Individuals with severe emotional difficulties should not abandon proven medical and psychological therapies but rather choose focusing as a possible adjunct.

• Folic acid: Folic acid or folate is a form of a water-soluble B vitamin needed for human health. Preliminary evidence suggests that folate may decrease the risk of several types of cancer. Additional research is needed to make a conclusion. Folic acid supplementation may mask the symptoms of pernicious, aplastic, or normocytic anemias caused by vitamin B12 deficiency and may lead to neurological damage.

• Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents and with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.

• Gamma linolenic acid (GLA): GLA is an omega-6 essential fatty acid. Some laboratory and human studies indicate that GLA may have anti-tumor activity and may be used as a cancer treatment adjunct. Additional research is needed in this area.

• Caution is advised when taking GLA supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. GLA should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Garlic: Preliminary human studies suggest that regular consumption of garlic (Allium sativum) supplements may reduce the risk of developing several types of cancer. Some studies use multi-ingredient products so it is difficult to determine if garlic alone may play a beneficial role in cancer prevention. Further well-designed human clinical trials are needed to conclude whether eating garlic or taking garlic supplements may prevent or treat cancer.

• Caution is advised when taking garlic supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Garlic should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Ginseng: Early studies report that ginseng taken by mouth may be of benefit in cancer prevention, especially if ginseng powder or extract is used. Weak studies suggest that ginseng in combination with other herbs may improve cell activity, immune function, and red and white blood cell counts in patients with aplastic anemia; however, other studies have found decreases in blood cell counts. Early studies suggest that ginseng may decrease radiation therapy side effects and may be used as a chemotherapy adjunct to improve body weight, quality of life, and the immune response. There is currently not enough evidence to recommend the use of Panax ginseng or American ginseng for these indications. Study results are unclear, and more research is needed before a clear conclusion can be reached.

• Caution is advised when taking ginseng supplements, as numerous adverse effects including an increased risk of drug interactions are possible. Ginseng should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Goji: Polysaccharide constituents, such as alpha- and beta-glucans from a variety of plants, are reported to have immune system enhancing properties. In clinical study, Lycium barbarum polysaccharides (LBP) demonstrated a synergistic effect in various cancer treatments, when administered in conjunction with powerful immune stimulating drugs.

• Use cautiously in patients who are taking blood-thinning medications, such as warfarin. Use cautiously in asthma patients and in patients with sulfite sensitivities. The New York Department of Agriculture has detected the presence of undeclared sulfites, a food additive, in two dried goji berry products from China. Avoid in patients who are allergic to goji, any of its constituents, or to members of the Solanaceae family.

• Grape seed: There is currently little information available on the use of grape seed extract in the treatment of human cancer. Further research is needed before a recommendation can be made.

• Avoid if allergic or hypersensitive to grapes or other grape compounds. Use cautiously with bleeding disorders or if taking blood thinners such as warfarin, aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), or anti-platelet agents. Use cautiously with drugs processed using the liver's cytochrome P450 enzyme system. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Avoid if pregnant or breastfeeding.

• Green tea: Green tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Green tea has a long history of use in health and longevity, dating back to China approximately 5,000 years ago. Although used for centuries to help prevent diseases, the relationship of green tea consumption and human cancer in general remains inconclusive. Evidence from well-designed clinical trials is needed before a firm conclusion can be made in this area.

• Caution is advised when taking green tea supplements, as numerous adverse effects including an increased risk of drug interactions are possible. Green tea should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Healing touch: Preliminary data suggests that healing touch (HT) may increase quality of life in cancer. However, due to weaknesses in design and the small number of studies, data are insufficient to make definitive recommendations. Studies with stronger designs are needed. HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.

• Hoxsey formula: "Hoxsey formula" is a misleading name, because it is not a single formula, but rather is a therapeutic regimen consisting of an oral tonic, topical (on the skin) preparations, and supportive therapy. The tonic is individualized for cancer patients based on general condition, location of cancer, and previous history of treatment. An ingredient that usually remains constant for every patient is potassium iodide. Other ingredients are then added and may include licorice, red clover, burdock, stillingia root, berberis root, pokeroot, cascara, Aromatic USP 14, prickly ash bark, and buckthorn bark. A red paste may be used, which tends to be caustic (irritating), and contains antimony trisulfide, zinc chloride, and bloodroot. A topical yellow powder may be used, and contains arsenic sulfide, talc, sulfur, and a "yellow precipitate." A clear solution may also be administered, and contains trichloroacetic acid.

• Well-designed human studies available evaluating the safety or effectiveness of Hoxsey formula are currently lacking. Caution is advised when taking the Hoxsey formula supplements, as numerous adverse effects including an increased risk of drug interactions are possible. Hoxsey formula should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Hydrazine sulfate: Hydrazine is an industrial chemical marketed as having the potential to repress weight loss and cachexia (muscle wasting) associated with cancer, and to improve general appetite status. However, in large randomized controlled trials, hydrazine has not been proven effective for improving appetite, reducing weight loss, or improving survival in adults. The National Cancer Institute (NCI) sponsored studies of hydrazine sulfate that claimed efficacy in improving survival for some patients with advanced cancer. Trial results found that hydrazine sulfate did not prolong survival for cancer patients. The U.S. Food and Drug Administration (FDA) has received requests from individual physicians for approval to use hydrazine sulfate on a case-by-case "compassionate use" basis on the chance that patients with no other available effective cancer treatment options might benefit from this therapy. The overall controversy in the use of hydrazine sulfate is ongoing, and relevance to clinical practice is unknown. The use of hydrazine sulfate needs to be evaluated further before any recommendations can be made.

• Hydrazine sulfate may cause cancer. Avoid if allergic or hypersensitive to hydrazine sulfate or any of its constituents. Use cautiously with liver or kidney problems, psychosis, diabetes or seizure disorders. Avoid if pregnant or breastfeeding. Side effects have been reported, including dizziness, nausea, and vomiting.

• Iodine: Iodine is an element (atomic number 53), which is required by humans for the synthesis of thyroid hormones (triiodothyronine/T3 and thyroxine/T4). The potential role of non-radioactive iodine in cancer care remains unknown. Antioxidant and anti-tumor effects have been proposed based on laboratory research. In contrast, some scientists have asserted that tumors may uptake more iodine than normal tissues. It has been suggested that high rates of gastric (stomach) cancer or low rates of breast cancer in coastal Japan may be due to high iodine intake, although this has not been demonstrated scientifically. Povidone-iodine solutions have been used as a part of alternative cancer regimens, such as the Hoxsey formula. Preliminary study has also indicated povidone-iodone solution as a potential rectal washout for rectal cancer. Overall, no clear conclusion can be drawn based on the currently available evidence.

• Reactions can be severe, and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis, or tuberculosis. Use cautiously when applying to the skin because it may irritate/burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.

• Jiaogulan: Preliminary evidence indicates that gypenosides extracted from Gynostemma pentaphyllum may decrease cancer cell viability, arrest the cell cycle, and induce apoptosis (cell death) in human cancer cells. Immune function in cancer patients has also been studied. Additional study is needed in this area.

• Avoid if allergic or hypersensitive to jiaogulan (Gynostemma pentaphyllum), its constituents, or members of the Cucurbitaceae family. Use cautiously with blood disorders or taking anticoagulants or anti-platelet drugs (blood thinners). Use cautiously with diabetes. Avoid if pregnant or breastfeeding.

• Lavender: Perillyl alcohol (POH), derived from lavender (Lavendula officinalis), may be beneficial in the treatment of some types of cancer. Preliminary small studies in humans, involving the use of POH suggest safety and tolerability, but effectiveness has not been established.

• Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

• Lutein: Currently, there is insufficient available evidence to recommend for or against the use of lutein for cancer. Available evidence in humans is conflicting.

• Avoid if allergic or hypersensitive to lutein or zeaxanthin. Use cautiously if at risk for cardiovascular disease or cancer. Avoid if pregnant or breastfeeding.

• Lycopene: High levels of lycopene are found in tomatoes and in tomato-based products. Tomatoes are also sources of other nutrients such as vitamin C, folate, and potassium. Several laboratory and human studies examining tomato-based products and blood lycopene levels suggest that lycopene may be associated with a lower risk of developing cancer and may help stimulate the immune system. However, due to a lack of well-designed human research using lycopene supplements, its effectiveness for cancer prevention in general, as well as breast cancer prevention, remains unclear.

• Avoid if allergic to tomatoes or to lycopene. Due to a lack of conclusive data, avoid if pregnant or breastfeeding.

• Maitake mushroom: Maitake is the Japanese name for the edible mushroom Grifola frondosa. Maitake has been used traditionally both as a food and for medicinal purposes. Early studies in the laboratory as well as in humans suggest that beta-glucan extracts from maitake may increase the body's ability to fight cancer. However, these studies have not been well designed, and better research is needed before the use of maitake for cancer can be recommended.

• Caution is advised when taking maitake supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Maitake should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Meditation: Not enough research has shown meditation to be of benefit in cancer prevention. More studies are needed.

• Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

• Melatonin: There are several early-phase and controlled human trials of melatonin in patients with various advanced stage malignancies. There is currently not enough definitive scientific evidence to discern if melatonin is beneficial as a cancer treatment, whether it increases (or decreases) the effectiveness of other cancer therapies, or if it safely reduces chemotherapy side effects.

• Melatonin is not to be used for extended periods of time. Caution is advised when taking melatonin supplements, as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding unless otherwise advised by a doctor.

• Milk thistle: Milk thistle (Silybum marianum) has been used medicinally in China for over 2,000 years, most commonly for the treatment of liver and gallbladder disorders. There are early reports from laboratory experiments that the components silymarin and silibinin found in milk thistle may reduce the growth of human cancer cells. However, effects have not been shown in high-quality human trials.

• Caution is advised when taking milk thistle supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Milk thistle should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Mistletoe: Mistletoe is one of the most widely used unconventional cancer treatments in Europe. Mistletoe extracts have been studied for a variety of human cancers as well as melanoma and leukemia. However, efficacy has not been conclusively proven for any one condition. In fact, some studies have shown lack of efficacy of certain preparations for a variety of cancers. Larger, well-designed clinical trials are needed.

• Caution is advised when taking mistletoe supplements, as numerous adverse effects including nausea, vomiting, and drug interactions are possible. Mistletoe should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Moxibustion: Moxibustion is a healing technique employed across the diverse traditions of acupuncture and oriental medicine for over 2,000 years. Moxibustion uses the principle of heat to stimulate circulation and break up congestion or stagnation of blood and chi. Moxibustion is closely related to acupuncture as it is applied to specific acupuncture points. Preliminary evidence suggests that moxibustion may reduce side effects of chemotherapy or radiation therapy. More studies are needed.

• Use cautiously over large blood vessels and thin or weak skin. Avoid with aneurysms, any kind of "heat syndrome," cardiac disease, convulsions or cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, inflammatory conditions, over allergic skin conditions or ulcerated sores, or skin adhesions. Avoid if pregnant or breastfeeding. Avoid areas with an inflamed organ, contraindicated acupuncture points, face, genitals, head, inflamed areas in general, nipples, and skin adhesions. Avoid in patients who have just finished exercising or taking a hot bath or shower. Use cautiously with elderly people with large vessels. It is considered not advisable to bathe or shower for up to 24 hours after a moxibustion treatment.

• Oleander: Laboratory studies of oleander (Nerium oleander) suggest possible anti-cancer effects, although reliable research in humans is not currently available. There are reports that long-term use of oleander may have positive effects in patients several types of cancer. More research is needed.

• Caution is advised when taking oleander supplements, as numerous adverse effects including drug interactions are possible. Oleander should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Omega-3 fatty acids: Omega-3 fatty acids are essential fatty acids found in some plants and fish. A balance of omega-6 and omega-3 fatty acids is advised for health. Several population studies report that dietary omega-3 fatty acids or fish oil may reduce the risk of developing several different types of cancer. Well conducted clinical trials are necessary before a clear conclusion can be drawn regarding the use of omega-3 fatty acids for cancer prevention.

• Caution is advised when taking omega-3 fatty acid supplements, as numerous adverse effects including an increase in bleeding and drug interactions are possible. Omega-3 fatty acid supplements should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Para-aminobenzoic acid: N-butyl-p-aminobenzoate (BAB) has been shown to be a lipid-soluble local anesthetic. Early study found significant pain relief in patients with intractable cancer pain after an epidural injection of BAB suspension. Larger scale clinical study is needed to confirm these findings.

• Avoid with known hypersensitivity to PABA or its derivatives. Avoid oral use in children and pregnant or nursing women. Use cautiously in patients with renal disease, bleeding disorders or taking anticoagulants, diabetics or patients at risk for hypoglycemia. Discontinue use if rash, nausea, or anorexia occurs. Pharmaceutical doses of PABA and its derivatives should only be taken under appropriate medical supervision. PABA should not be given concurrently with sulfonamides.

• Perillyl alcohol: Perillyl alcohol has been used to treat cancer. However, high quality scientific studies are lacking. Further research is required before recommendations can be made.

• Avoid if allergic/hypersensitive to perillyl alcohol. Avoid use in the absence of medical supervision. Use cautiously in patients under medical supervision. Avoid if pregnant or breastfeeding.

• Physical therapy: Physical therapy was first documented in China around 3000 BC with the use of joint manipulation and massage to relieve pain. The goal of physical therapy or physiotherapy is to improve mobility, restore function, reduce pain, and prevent further injury by using a variety of methods, including exercises, stretches, traction, electrical stimulation, and massage. Physical therapy programs are often used following mastectomy (breast cancer surgery), which may include arm mobilization, shoulder strengthening, prevention and treatment of upper extremity edema (swelling), and education about arm function. Limited available study suggests that physical therapy may increase shoulder range of motion following breast cancer surgery, but more high quality trials are needed.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Prayer: Initial studies of prayer in patients with cancer (such as leukemia) report variable effects on disease progression or death rates when intercessory prayer is used. Better quality research is necessary before a firm conclusion can be drawn.

• Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers. In clinical study, patients certain that they were receiving intercessory prayer had a higher incidence of complications following cardiac bypass surgery than those who did not know they were being prayed for.

• Reiki: Reiki may contribute to reduced perception of pain, improved quality of life, and reduced fatigue in cancer patients. More studies are needed.

• Reiki is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.

• Reishi mushroom: Reishi (Ganoderma lucidum) has been shown to have antineoplastic and immunomodulatory effects in animal studies. Human studies exist of advanced cancer patients using Ganopoly®, a Ganoderma lucidum polysaccharide extract. Results show improved quality of life and enhanced immune responses, which are typically reduced or damaged in cancer patients receiving chemotherapy and/or radiation therapy. Well-designed long-term studies are needed confirm these results and to determine potential side effects.

• Caution is advised when taking reishi supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Reishi should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Resveratrol: The effects of resveratrol cannot be adequately assessed from trials using foods, wine, or combination products containing resveratrol and other substances. Well-designed clinical trials of resveratrol alone are needed before a recommendation can be made in regards to cancer prevention and/or treatment.

• Avoid if allergic or hypersensitive to resveratrol, grapes, red wine or polyphenols. Resveratrol is generally considered safe and is commonly found in food and beverages. Use cautiously with bleeding disorders, abnormal blood pressure. Use cautiously with drugs that are broken down by the body's cytochrome P450 system or digoxin (or digoxin-like drugs). Avoid if pregnant or breastfeeding.

• Seaweed: Bladderwrack (Fucus vesiculosus) is a brown seaweed that grows on the northern coasts of the Atlantic and Pacific oceans, and the North and Baltic seas. Bladderwrack appears to suppress the growth of various cancer cells in animal and laboratory studies. However, reliable human studies to support a recommendation for use in cancer are currently lacking.

• Caution is advised when taking bladderwrack supplements, as numerous adverse effects including an increased risk of drug interactions are possible. Bladderwrack should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Selenium: Selenium is a trace mineral found in soil, water, and some foods. It is an essential element in several metabolic pathways. Several studies suggest that low levels of selenium (measured in the blood or in tissues such as toenail clippings), may be a risk factor for developing cancer. Population studies suggest that people with cancer are more likely to have low selenium levels than healthy matched individuals, but in most cases it is not clear if the low selenium levels are a cause or merely a consequence of disease. It currently remains unclear if selenium is beneficial for cancer prevention or cancer treatment.

• Avoid if allergic or sensitive to products containing selenium. Avoid with a history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.

• Shark cartilage: For several decades, shark cartilage has been proposed as a cancer treatment. Studies have shown shark cartilage or the shark cartilage product AE-941 (Neovastat®) to block the growth of new blood vessels, a process called "anti-angiogenesis," which is believed to play a role in controlling growth of some tumors. There have also been several reports of successful treatments of end-stage cancer patients with shark cartilage, but these have not been well-designed and have not included reliable comparisons to accepted treatments. Many studies have been supported by shark cartilage product manufacturers, which may influence the results. In the United States, shark cartilage products cannot claim to cure cancer, and the U.S. Food and Drug Administration (FDA) has sent warning letters to companies not to promote products in this way. Without further evidence from well-designed human trials, it remains unclear if shark cartilage is of any benefit in cancer and patients are advised to check with their doctor and pharmacist before taking shark cartilage.

• Shark cartilage available in Asian grocery stores and restaurants should not be eaten due to declining populations of sharks. Caution is advised when taking shark cartilage supplements, as numerous adverse effects including an increased risk of drug interactions are possible. Shark cartilage should not be used by patients who are pregnant or breast-feeding, unless otherwise directed by a doctor.

• Shiitake mushroom: Shiitake (Lentinus edodes) has been taken by mouth for boosting the immune system, decreasing cholesterol levels, and for anti-aging. Lentinan, derived from shiitake, has been injected as an adjunct treatment for cancer and HIV infection. Laboratory, animal and human studies of lentinan have shown positive results in cancer patients when used as a chemotherapy adjunct. Further well-designed clinical trials on all types of cancer are required to confirm these results.

• Caution is advised when taking shiitake supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Shiitake should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Slippery elm: Slippery elm is found as a common ingredient in a purported herbal anticancer product called Essiac® and a number of Essiac-like products. These products contain other herbs such as rhubarb, sorrel, and burdock root. Currently, there is not enough evidence to recommend for or against the use of this herbal mixture as a therapy for any type of cancer. Avoid if allergic or hypersensitive to slippery elm. Avoid if pregnant or breastfeeding.

• Sorrel: Early evidence suggests that herbal formulations containing sorrel, such as Essiac®, do not shrink tumor size or increase life expectancy in patients with cancer. However, currently there is a lack of studies evaluating sorrel as the sole treatment for cancer. A conclusion cannot be made without further research.

• Avoid with a known allergy or hypersensitivity to sorrel. Avoid large doses due to reports of toxicity and death, possibly because of the oxalate found in sorrel. Many tinctures contain high levels of alcohol and should be avoided when driving or operating heavy machinery. Sorrel formulations may cause nausea or vomiting when taken with the prescription drugs metronidazole (Flagyl®) or disulfiram (Antabuse®). Avoid if pregnant or breastfeeding.

• Soy: Soy (Glycine max) contains compounds which have been reported to be effective as a cancer treatment. Genistein, an isoflavone found in soy, has been found in laboratory and animal studies to possess anti-cancer effects, such as blocking new blood vessel growth (anti-angiogenesis), acting as a tyrosine kinase inhibitor (a mechanism of many new cancer treatments), or causing cancer cell death (apoptosis). In contrast, genistein has also been reported to increase the growth of pancreas tumor cells in laboratory research. Until reliable human research is available, it remains unclear if dietary soy or soy isoflavone supplements are beneficial, harmful, or neutral in people with various types of cancer.

• Several large population studies have asked women about their eating habits, and reported higher soy intake (such as dietary tofu) to be associated with a decreased risk of developing breast cancer. This type of research can only be considered preliminary, because people who choose to eat soy may also partake in other lifestyle decisions that may lower the risk of cancer and be the cause of the benefits seen in these studies (for example, lower fat intake, more frequent exercise, lack of smoking). Until better research is available, it remains unclear if dietary soy or soy isoflavone supplements increase or decrease the risk of developing breast cancer.

• Caution is advised when taking soy supplements, as numerous adverse effects including an increased risk of drug interactions are possible. Soy should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Spiritual healing: Cancer patients, especially those who fear recurrence or are unhappy with their physicians, commonly use prayer and spiritual healing. More research is needed to address the effects of spiritual healing on anxiety, depression, and quality of life in patients with cancer.

• Spiritual healing should not be used as the only treatment approach for medical or psychiatric conditions, and should not delay the time it takes to consider more proven therapies.

• Sweet annie: Certain constituents found in sweet annie show promise for use in cancer when used in combination with standard chemotherapy. However, currently there is not enough scientific evidence in humans to make a strong recommendation for this use.

• Avoid if allergic or hypersensitive to sweet annie (Artemisia annua), its constituents, or members of the Asteraceae/Compositae family such dandelion, goldenrod, ragweed, sunflower, and daisies. Use cautiously in patients who are pregnant, taking angiogenic agents, or recovering from surgery or other wounds. Use cautiously if taking cardiotoxic or neurotoxic agents or with compromised cardiac or neural function. Use cautiously if taking immunostimulants or quinolines. Avoid if pregnant or breastfeeding.

• Tai chi: Tai chi is a system of movements and positions believed to have developed in 12th century China. Tai chi techniques aim to address the body and mind as an interconnected system, and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility and strength. Tai chi chuan has been studied in breast cancer patients to improve functional capacity (specifically aerobic capacity, muscular strength, and flexibility). Larger studies are needed to make a firm recommendation.

• Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

• Transcutaneous electrical nerve stimulation (TENS): Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Although TENS has been used with some success in cancer pain, there is not enough reliable evidence to draw a firm conclusion in this area. TENS is often used in combination with acupuncture.

• Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

• Thiamin (Vitamin B1): Thiamin deficiency has been observed in some cancer patients, possibly due to increased metabolic needs. It is not clear if lowered levels of thiamin in such patients may actually be beneficial. Currently, it remains unclear if thiamin supplementation plays a role in the management of any particular type(s) of cancer.

• Thiamin is generally considered safe and relatively nontoxic. Avoid if allergic or hypersensitive to thiamin. Rare hypersensitivity/allergic reactions have occurred with thiamin supplementation. Skin irritation, burning, or itching may rarely occur at injection sites. Large doses may cause drowsiness or muscle relaxation. Use cautiously if pregnant or breastfeeding.

• Thymus extract: Preliminary evidence suggests that thymus extract may increase disease-free survival and immunological improvement in several types of cancer. Additional study is needed in this area.

• Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding.

• Traditional Chinese Medicine (TCM): The ancient Chinese philosophy of Taoism provided the basis for the development of Chinese medical theory. TCM uses over 120 different herbs in cancer treatment, depending on the type of cancer and its cause according to Chinese medical theory. Studies have reported significant benefits include reducing tumors, reducing treatment side effects and improved response to treatment. More studies of stronger design are needed before TCM can be recommended with confidence as an adjunct to cancer treatment, although centuries of traditional use in cancer cannot be discounted.

• Chinese herbs can be potent and may interact with other herbs, foods or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in ephedra. Avoid ginseng if pregnant or breastfeeding.

• Turmeric: Turmeric (Curcuma longa) is commonly used for its anti-inflammatory properties. Several early animal and laboratory studies report anti-cancer (colon, skin, breast) properties of curcumin. Many mechanisms have been considered, including antioxidant activity, anti-angiogenesis (prevention of new blood vessel growth), and direct effects on cancer cells. Currently it remains unclear if turmeric or curcumin has a role in preventing or treating human cancer. There are several ongoing studies in this area.

• Caution is advised when taking turmeric supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Turmeric should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

• Vitamin A: Vitamin A is a fat-soluble vitamin, which is derived from retinoids and carotenoids. Retinoids like retinal and retinoic acid are found in animal sources (like the liver, kidney, eggs and dairy products). Carotenoids like beta-carotene are found in plants like dark or yellow vegetables and carrots. Research results are not clear as to whether vitamin A is beneficial in the treatment or prevention of breast cancer.

• Patients receiving chemotherapy or radiation therapy for cancer should speak with their doctor(s) before taking antioxidants such as vitamin A during treatment, due to possible interference. Vitamin A toxicity can occur if taken at high dosages, and caution should be used with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may be at an increased risk for lung cancer or heart disease. Vitamin A appears safe in pregnant women if taken at recommended doses. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.

• Vitamin B12: Vitamin B12 (or cyanocobalamin) is an essential water-soluble vitamin that is commonly found in a variety of foods such as fish, shellfish, meats, and dairy products. Researchers at Johns Hopkins University report that women with breast cancer tend to have lower vitamin B12 levels in their blood serum than do women without breast cancer. In a subsequent review of these findings, it was hypothesized that vitamin B12 deficiency may lead to breast cancer because it may result in less folate being available to ensure proper DNA replication and repair. Higher dietary folate intake is associated with a reduced risk of breast cancer. The risk may be further reduced in women who also consume high amounts of dietary vitamin B12 in combination with dietary pyridoxine (vitamin B6) and methionine. However, there is currently insufficient evidence that dietary vitamin B12 alone reduces the risk of breast cancer.

• Avoid if allergic or hypersensitive to cobalamin, cobalt, or any other vitamin B12 product ingredients. Avoid with coronary stents (mesh tube that holds clogged arteries open) and Leber's disease. Use cautiously if undergoing angioplasty and with anemia. Vitamin B12 is generally considered safe when taken in amounts that are not higher than the Recommended Dietary Allowance (RDA). There is currently not enough scientific data available about the safety of larger amounts of vitamin B12 during pregnancy and/or breastfeeding.

• Vitamin C (ascorbic acid): Dietary intake of fruits and vegetables high in vitamin C has been associated with a reduced risk of various types of cancer in population studies (particularly cancers of the mouth, esophagus, stomach, colon, or lung). However, it is not clear that it is specifically the vitamin C in these foods that is beneficial, and vitamin C supplements have not been found to be associated with this protective effect. Experts have recommended increasing dietary consumption of fruits and vegetables high in vitamin C, such as apples, asparagus, berries, broccoli, cabbage, melon (cantaloupe, honeydew, watermelon), cauliflower, citrus fruits (lemons, oranges), fortified breads/grains/cereal, kale, kiwi, potatoes, spinach, and tomatoes. Vitamin C has a long history of adjunctive use in cancer therapy, and although there have not been any definitive studies using intravenous (or oral) vitamin C, there is evidence that it has benefit in some cases. Better-designed studies are needed to better determine the role of vitamin C in cancer prevention and cancer treatment.

• Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods. Vitamin C supplements are also generally considered safe in most individuals if taken in recommended doses. Large doses (greater than 2 grams) may cause diarrhea and gastrointestinal upset. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder). Vitamin C intake from food is generally considered safe if pregnant or breastfeeding. It is not clear if vitamin C supplements in doses higher than Dietary Reference Intake recommendations are safe for pregnant or breastfeeding women. Vitamin C is naturally found in breast milk.

• Vitamin D: Limited research suggests that synthetic vitamin D analogs may play a role in the treatment of human cancers. However, it remains unclear if vitamin D deficiency raises cancer risk, or if an increased intake of vitamin D is protective against some cancers. Until additional trials are conducted, it is premature to advise the use of regular vitamin D supplementation for cancer prevention. High-dose vitamin D supplementation may be associated with a slightly reduced risk of developing breast cancer. Additional study in this area is warranted.

• Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.

• Vitamin E: Reliable scientific evidence that vitamin E is effective as a cancer treatment is currently lacking. Vitamin E has been suggested as a possible therapy for the prevention or treatment of breast cancer.

• Caution is merited in people undergoing chemotherapy or radiation, because it has been proposed that the use of high-dose antioxidants may actually reduce the anti-cancer effects of these therapies. This remains an area of controversy and studies have produced variable results. Patients interested in using high-dose antioxidants such as vitamin E during chemotherapy or radiation should discuss this decision with their medical oncologist or radiation oncologist. Caution is advised when taking vitamin E supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid above the recommended daily level in pregnant women and breastfeeding women.

• Fair negative scientific evidence:

• Apricot: Available clinical trials on the use of whole apricots for cancer are currently lacking. However, some research has been conducted on "Laetrile™," an alternative cancer drug marketed in Mexico and other countries outside of the U.S. Laetrile™ is derived from amygdalin found in apricot pits and nuts such as bitter almond. There are multiple animal studies and initial human evidence to suggest that Laetrile™ is not beneficial in the treatment of cancer. Based on a phase II trial in 1982, the U.S. National Cancer Institute concluded that Laetrile™ is not an effective chemotherapeutic agent. Nonetheless, many people still travel to use this therapy outside the U.S.

• Multiple cases of cyanide poisoning, including deaths, have been associated with Laetrile™ therapy. Avoid if allergic to apricot, its constituents or members of the Rosaceae family, especially the Prunoideae subfamily of plants. Avoid eating excessive amounts of apricot kernels (about 7 grams daily, or more than ten kernels daily). Use cautiously with diabetes. Use cautiously when taking supplements containing beta-carotene, iron, niacin, potassium, thiamine or vitamin C. Use cautiously when taking products that may lower blood pressure. Avoid if pregnant or breastfeeding.

• Beta-carotene: While diets high in fruits and vegetables rich in beta-carotene have been shown to potentially reduce certain cancer incidences, results from randomized controlled trials with oral supplements do not support this claim.

• There is some concern that beta-carotene metabolites with pharmacological activity can accumulate and potentially have cancer-causing (carcinogenic) effects. A higher, statistically significant incidence of lung cancer in male smokers who took beta-carotene supplements has been discovered. Beta-carotene/vitamin A supplements may have an adverse effect on the incidence of lung cancer and on the risk of death in smokers and asbestos exposed people or in those who ingest significant amounts of alcohol. In addition, high-dose antioxidants theoretically may interfere with the activity of some chemotherapy drugs or radiation therapy. Therefore, individuals undergoing cancer treatment should speak with their oncologist if they are taking or considering the use of high dose antioxidants. Beta-carotene in the amounts normally found in food does not appear to have this adverse effect. Avoid if sensitive to beta-carotene, vitamin A or any other ingredients in beta-carotene products.

• Bitter almond: "Laetrile" is an alternative cancer drug marketed in Mexico and other countries outside of the United States. Laetrile is derived from amygdalin, found in the pits of fruits and nuts such as the bitter almond. Early evidence suggests that laetrile is not beneficial in the treatment of cancer. In 1982, the U.S. National Cancer Institute concluded that laetrile was not effective for cancer therapy. Nonetheless, many people still travel to use this therapy outside the United States.

• Multiple cases of cyanide poisoning, including deaths, have been associated with laetrile therapy. Avoid if allergic to almonds or other nuts. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding because of the risk of birth defects.

• Hypnotherapy, hypnosis: Hypnosis did not reduce radiotherapy side effects such as anxiety and did not improve quality of life in patients undergoing curative radiotherapy in early high-quality studies.

• Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders, or with seizure disorders.

• Iridology: There is currently limited available data supporting iridology as a tool for cancer diagnosis. Additional study is needed.

• Iridology should not be used alone to diagnose disease. Studies of iridology have reported incorrect diagnoses, and thus, potentially severe medical problems may go undiagnosed. In addition, research suggests that iridology may lead to inappropriate treatment. Iridology is therefore not recommended as a sole method of diagnosis or treatment for any condition.

• PSK: The available evidence does not support the use of PSK, in conjunction with hormone therapy, chemotherapy, and/or surgery, to increase survival rates in breast cancer patients.

• Avoid if allergic or hypersensitive to PSK, Coriolus versicolor, or any of its ingredients. Use cautiously with coronary artery disease. Avoid if pregnant or breastfeeding.

• Vitamin E: Recent evidence from well-conducted clinical study reports no reduction in the development of cancer with the use of natural-source vitamin E taken daily. Previously, there have been laboratory, population, and other human trials examining whether vitamin E is beneficial in general cancer prevention, including that for prostate, colon, or stomach cancer. Results of these prior studies have been variable. At this time, based on the best available scientific evidence, and recent concerns about the safety of vitamin E supplementation, vitamin E cannot be recommended for cancer prevention.

• Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid above the recommended daily level in pregnant women and breastfeeding women.

Prevention

• Physical activity: Regular exercise may reduce the complications of breast cancer and reduce the risks of developing the disease. Large studies support household activity as being associated with a significantly reduced risk of breast cancer in postmenopausal and premenopausal women.

• Diet: Reducing fat and red meat while increasing vegetables and whole grains may reduce the chances of developing breast cancer. One large study of almost 2500 women found that a lifestyle intervention reducing dietary fat intake, with modest influence on body weight, might improve relapse-free survival of breast cancer patients receiving conventional cancer management. In one study, during 12 years of follow-up of 90,659 premenopausal women, the greater the red meat intake correlated with an elevated risk of breast cancers that were estrogen and progesterone receptor positive, but not to those that were estrogen and progesterone receptor negative.

• An increase in fiber has also been reported to reduce the chances of developing breast cancer.

• The phytochemical (plant-chemical) indole-3-carbinol, found in cruciferous vegetables like cabbage and broccoli might directly contribute to breast cancer protection. An increase in soy and soy products as source of isoflavones was found to be inversely associated with high mammographic density, a marker for breast cancer risk. Estrogenic activity by soy may be linked to breast cancer development in some studies, with other studies reporting no correlation between dietary phytoestrogens and breast cancer.

• Weight loss: A lower body mass index (BMI) has been correlated with a lower chance of developing breast cancer.

• Decrease alcohol consumption: Although a glass of wine may be beneficial for heart health, findings from a prospective study suggest that moderate alcohol consumption may increase the risk of breast cancer risk. It should be noted that some components of alcoholic beverages, such as hops have estrogenic activity, which may be linked to breast cancer development in some studies. However, some studies have reported no correlation between dietary phytoestrogens and breast cancer.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

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