Related Terms

• Aflatoxins, alanine aminotransferase, alkaline phosphatase, ALP, alpha-fetoprotein, ALT, angiosarcoma, ascites, aspartate aminotransferase, AST, bilirubin, cancer, choangiocarcinoma, cirrhosis, HBV, HCV, hemangiosarcoma, hemochromatosis, hepatitis B, hepatitis C, hepatoblastoma, hepatocellular carcinoma, hepatocytes, hepatoma, jaundice, liver biopsy, metastatic, primary sclerosing cholangitis.

Background

• Liver cancer is a cancer affecting the liver characterized by abnormal tumors or growths. Primary liver cancer or hepatoma forms in the tissues of the liver. Secondary liver cancer arises when cancer in other parts of the body spreads to the liver; the most common types of cancer that spread to the liver start in the bowel, breast, pancreas, stomach, lung, ovary, or skin (melanoma).

• The liver is made up of cells called hepatocytes. The majority (over 90-95%) of primary liver cancer arises from these liver cells and is called hepatocellular carcinoma (cancer).

• The liver is the second largest organ in the body (after the skin), and is essential in keeping the body functioning properly. The liver is located in the upper right-hand side of the abdomen. It performs many functions in the body, including processing the body's nutrients, manufacturing bile to help digest fats, synthesizing many important proteins, regulating blood clotting, and breaking down potentially toxic substances into harmless ones that the body can use or excrete.

• Liver cancer is the fifth most common cancer in the world and the majority of patients with liver cancer will die within one year as a result of the cancer. Because the liver is close to or actually connected to several significant organs, and because the liver plays an important role in blood circulation by acting as a filter, metastatic (spreading) liver cancer occurs in over 75% of all terminal cancer patients.

• In the United States, individuals with liver cirrhosis (a condition that causes irreversible damage to liver cells) caused by chronic hepatitis B or C infections, alcohol, and hemochromatosis (an inherited disease causing too much iron in the body) are at the greatest risk of developing liver cancer.

• For some individuals with liver cancer, liver transplantation offers the best chance for cure.

Types of Liver Cancer

• Primary liver cancer: Primary liver cancer is divided into several types based on the type of cells that become cancerous. Types include hepatocellular carcinoma, choangiocarcinoma, hepatoblastoma, and angiosarcoma or hemangiosarcoma.

• Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer in both children and adults. It starts in the hepatocytes, the main type of liver cell.

• Cholangiocarcinoma begins in the small tube-like bile ducts within the liver. This type of cancer is sometimes called bile duct cancer.

• Hepatoblastoma is a rare type of liver cancer arising in immature liver precursor cells. Hepatoblastoma affects children younger than four years of age. Most children with hepatoblastoma can be successfully treated.

• Angiosarcoma and hemangiosarcoma are rare cancers that begin in the blood vessels of the liver and grow very quickly.

• Metastatic cancer: In the United States, most cancer found in the liver has spread there from another part of the body. Rather than being referred to as liver cancer, this type of cancer is usually named after the organ where it originated and is described as "metastatic." For instance, cancer that has spread to the liver from the colon is referred to as metastatic colon cancer.

• Metastatic cancers form when malignant cells detach from the primary cancer and travel through the body in the circulatory or lymphatic system. Cancers that begin in certain organs near the liver, such as the pancreas, can spread directly to the liver. Most metastatic cancers reach the liver through the bloodstream.

Causes and Risk Factors

• Liver cancer occurs when liver cells begin to grow abnormally. It is not completely understood why this happens, but researchers believe that cancer starts with damage to DNA. DNA is the material that contains the instructions for every chemical process in the body, including the rate of cellular growth. DNA damage causes changes in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor (a mass of cancer cells).

• Gender: Men are more likely to develop primary liver cancer than are women, although the reasons why are not clear.

• Age: In the United States and Europe, liver cancer diagnosis occurs on average at about age 60. People in Asia and Africa tend to be diagnosed with liver cancer at younger ages, between ages 20-50.

• Chronic infection with HBV or HCV: Chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) is a risk factor for developing liver cancer. Hepatitis infections can damage liver cells and alter DNA, leading to cancer development.

• Cirrhosis: Cirrhosis is a progressive and irreversible condition that causes scar tissue to form in the liver and increases the individual's chances of developing liver cancer. Causes of cirrhosis include alcoholism, hepatitis, and exposure to environmental toxins.

• Diabetes: Individuals with diabetes have a greater risk of liver cancer. Having both diabetes and hepatitis C infection increases the risk even more. Diabetes can damage small capillaries that deliver blood and nutrients to organs such as the liver and kidney. Toxins may build up in the liver, causing further damage.

• Exposure to aflatoxins: Aflatoxins are toxic metabolites produced by certain fungi in or on foods and animal feeds. Consuming foods contaminated with fungi that produce aflatoxins greatly increases the risk of liver cancer. Crops such as corn, soybeans, and peanuts can become contaminated with aflatoxins.

• Excessive alcohol consumption: Consuming more than a moderate amount of alcohol can lead to irreversible liver damage and increase the risk of liver cancer. Moderate consumption is defined as no more than two drinks a day for men and one drink for women. A drink is one 4-5 ounce glass of wine, 12 ounces of beer, or a 1.5-ounce shot of 80-proof distilled spirits.

• Smoking: Cigarette smoking increases the chances of developing liver cancer. Risks of developing liver cancer are also found to increase significantly with increasing number of years of cigarette use and with earlier age at the start of cigarette smoking.

Signs and Symptoms

• Most individuals do not have signs and symptoms in the early stages of liver cancer. Unfortunately, the disease may not be detected until it is in an advanced stage. When symptoms do appear, they may include: loss of appetite and weight; abdominal pain, especially in the upper right part of the abdomen, which may extend into the back and shoulder; nausea and vomiting; general weakness and fatigue; an enlarged liver and abdominal swelling (ascites); and jaundice, or a yellow discoloration of the skin and the whites of the eyes.

Complications

• Liver failure: Liver failure means that the liver is losing or has lost all of its function. It is a life-threatening condition that demands urgent medical care. The first symptoms of liver failure are often nausea, loss of appetite, fatigue, and diarrhea. Because these symptoms can have any number of causes, it may be hard to tell that the liver is failing.

• As liver failure progresses, the symptoms become more serious. The individual may become confused and disoriented, and extremely sleepy. There is a risk of coma and death. Immediate treatment is needed. The medical team will try to save whatever part of the liver that is still working. If this is not possible, the only option may be a liver transplant.

• Kidney failure: The kidneys may lose their ability to filter fluids and waste, causing dangerous levels of toxic substances to accumulate in the body. Blood pressure may rise; the body may retain excess fluid and not make enough red blood cells.

• Metastasis: Metastasis is when cancer that spreads to areas outside the affected organ and becomes more difficult to treat. Liver cancer most commonly spreads to the lungs and bones. The liver is the second most commonly involved organ by metastatic disease, after the lymph nodes.

Diagnosis

• The American Association for the Study of Liver Diseases recommends liver cancer screening for those thought to have a high risk, including people who have hepatitis B and also fall into one or more of the following categories: an Asian male older than 40, an Asian female older than 50, or an African older than 20 with liver cirrhosis or a family history of liver cancer. Other high risks include: liver cirrhosis from alcohol use; hepatitis C; an inherited form of hemochromatosis; and primary sclerosing cholangitis. Screening typically involves blood tests and an ultrasound exam once or twice each year.

• Blood tests:

• Albumin: Serum albumin levels measures the main protein made by the liver and tells how well the liver is making this protein. Albumin, produced only in the liver, is the major plasma protein that circulates in the bloodstream.

• Ammonia: An ammonia test measures the amount of ammonia in the blood. Most ammonia in the body forms when protein is broken down by bacteria in the intestines. The liver normally converts ammonia into urea, which is then eliminated in urine. Ammonia levels in the blood rise when the liver is not able to convert ammonia to urea. This may be caused by cirrhosis or severe hepatitis.

• Alpha-fetoprotein (AFP) test: If the patient has high levels of the alpha-fetoprotein in the blood, it may be a sign of liver cancer. Healthy adult males and non-pregnant females typically have less than 40 micrograms of alpha-fetoprotein per liter of blood. AFP is a protein normally made by the immature liver cells in the fetus. At birth, infants have relatively high levels of AFP, which fall to normal adult levels by the first year of life. Also, pregnant women carrying babies with neural tube defects may have high levels of AFP. In adults, high blood levels (over 500 nanograms per milliliter) of AFP are seen in only three situations: hepatocellular cancer, germ cell tumors (cancer of the testes and ovaries), and metastatic cancer in the liver.

• Bilirubin: Bilirubin is a waste product made from old blood cells broken down in the liver; it is a yellow compound that causes jaundice and dark urine when present in increased amounts. Tests for bilirubin levels help determine if the liver is functioning appropriately.

• Liver enzymes: Another blood test may be performed to check for elevated levels of liver enzymes contained in liver cells, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST). These enzymes leak into the bloodstream when liver cells are injured. Also, alkaline phosphatase (ALP) levels may be checked. ALP is an enzyme related to the bile ducts. ALP levels are often increased when they are blocked.

• Transferrin saturation test: The transferrin saturation test reveals how much iron is bound to the protein that carries iron in the blood. Transferrin saturation tests are used in determining if hemochromatosis exists. Transferrin saturation values higher than 45% are considered too high. The total iron binding capacity test measures how well the blood can transport iron, and the serum ferritin test shows the level of iron in the liver. If either of these tests shows higher than normal levels of iron in the body, doctors can order a special blood test to detect the gene responsible for hemochromatosis, which will confirm the diagnosis. If the mutation is not present, hereditary hemochromatosis is not the reason for the iron buildup and the doctor will look for other causes.

• Diagnostic tests:

• Ultrasound: An ultrasound test uses sound waves to produce a picture of internal organs, including the liver. Ultrasound is painless and usually takes less than 30 minutes. While the individual lies on a bed or examining table, a wand-shaped device (transducer) is placed on the body. This wand emits sound waves that are reflected from the liver and transformed into a computer image. Ultrasound provides information about the shape, texture and makeup of tumors.

• Computerized tomography (CT) scan: Computerized tomography (CT) uses x-rays to produce cross-sectional images of the body. A variation of a CT, called the CT angiogram, may also be performed instead of a CT. In a CT angiogram, a contrast dye is injected into an artery in the liver. X-rays then track the dye as it flows through the blood vessels in the liver. This type of angiogram, which may take up to an hour to perform, can provide detailed information on the number and location of liver tumors. However, some individuals may experience an allergic reaction to the contrast dye.

• Magnetic resonance imaging (MRI): Magnetic resonance imaging (MRI) creates images using a magnetic field and radio waves. Sometimes a contrast dye also may be used. The test can take from 15 minutes to an hour. Newer MRIs can show images of the ducts that transport bile from the liver to the upper part of the small intestine (duodenum) as well as of the arteries and veins within the liver. Sedatives, such as alprazolam (Xanax®) may be used in individuals sensitive to being in closed in spaces. In these cases, a friend or relative needs to drive the individual home from the MRI scan. Sedatives may cause drowsiness and impair the ability to drive an automobile.

• Liver biopsy: A liver biopsy may be performed to determine the extent of cellular liver damage and to determine the best treatment option for the patient. During the procedure, a needle is inserted into the liver and a small tissue sample is removed. The tissue is then analyzed under a microscope in a laboratory.

• Staging:

• Staging tests help designate the size and location of cancer and whether it has spread. Liver cancer may be staged in different ways. One method uses the Roman numerals I through IV, with higher numbers indicating cancers that are more advanced, such as spreading to other organs. A stage I tumor is small and confined to one lobe of the liver. By stage IV, several tumors may exist in different lobes, or malignant cells may have metastasized (spread) to other parts of the body.

• Doctors may also use the following stages to describe primary liver cancer in adults:

• Localized resectable: When liver cancer is at the localized resectable stage, the tumor is confined to one lobe of the liver and can be completely removed in an operation. Resectable means a tumor that can be surgically removed.

• Localized unresectable: A localized unresectable cancer is found in only one part of the liver. Localized unresectable cancer cannot be completely removed, either because the noncancerous portion of the liver is not healthy enough or because the cancer is located too near the liver's main arteries, veins, and bile ducts and cannot be removed without causing serious damage to the organ.

• Advanced: In advanced liver cancer, the cancer has spread throughout the liver or to other parts of the body, particularly the bones or lungs. The individual is more likely to have advanced cancer if they also have cirrhosis or chronic hepatitis.

• Recurrent: Recurrent liver cancer means the cancer has returned to the liver or to another part of the body after being treated.

Treatment

• Treatments for primary liver cancer depend on the extent (stage) of the disease as well as age, overall health, feelings, and personal preferences. It is important to discuss all of the options carefully with a treatment team.

• The goal of any treatment is to eliminate the cancer completely. When elimination is not possible, the focus may be on preventing the tumor from growing or spreading. In some cases palliative care only is appropriate. Palliative care refers to treatment aimed not at removing or slowing the disease, but at helping relieve symptoms, such as pain, and making the individual as comfortable as possible.

• Surgery: The best treatment for localized resectable liver cancer is usually an operation known as surgical resection. In some cases, the area of the liver where the cancer is found can be completely removed. Individuals are not candidates for surgical removal of liver tumors if cirrhosis or only a small amount of healthy liver tissue exists. Even when resections are successful, there is a chance the cancer can recur elsewhere in the liver or in other areas of the body within a few years. It is difficult for surgeons to remove all damaged liver cells that may be cancerous.

• Alcohol injection: In an alcohol injection procedure, pure alcohol is injected directly into tumors, either through the skin or during an operation. Alcohol dries out the cells of the tumor and eventually the cells die. Each treatment consists of one injection, although the individual may need a series of injections for the best results. Alcohol injection has been shown to improve survival in those with small hepatocellular tumors. It may also be used to help reduce symptoms in cases of metastatic liver cancer. Leaking of alcohol onto the liver or into the abdominal cavity can occur and may cause tissue irritation.

• Radiofrequency ablation: In a radiofrequency ablation procedure, electric current in the radiofrequency range is used to destroy malignant cells. A surgeon inserts several thin needles into small incisions in the abdomen using an ultrasound or computerized tomography (CT) scan as a guide. The needles are heated with electrical current when they reach the tumor, destroying the malignant cells with heat. Radiofrequency ablation is an option for those with small, unresectable hepatocellular tumors and for some types of metastatic liver cancers.

• Chemoembolization: Chemoembolization is a type of chemotherapy treatment that supplies strong anti-cancer drugs directly to the liver. Chemoembolization does not cure liver cancer, but it can shrink tumors in a certain percentage of individuals, which may provide symptom relief and improve survival. During the procedure, the hepatic artery (the artery from which liver cancers derive their blood supply) is blocked, and chemotherapy drugs are injected between the blockage and the liver. By targeting the tumor directly, doctors can use potent doses of drugs without creating as many side effects as would occur with systemic chemotherapy. Chemoembolization is less likely to cause some side effects such as lowered blood cell counts or hair loss, but may still cause some side effects such as nausea and vomiting.

• Cryoablation: Cryobalation, also known as cryosurgery or cryotherapy, is a treatment that uses extreme cold to destroy cancer cells. Cryoablation may be an option for those individuals with inoperable primary and metastatic liver cancers. It may also be used in addition to surgery, chemotherapy, or other standard treatments. During the procedure, a doctor places an instrument (cryoprobe) containing liquid nitrogen directly onto liver tumors. Ultrasound images are used to guide the cryoprobe and monitor the freezing of the cells, which destroys the cancerous cells. Side effects include damage to the bile ducts and major blood vessels, leading to bleeding or infection.

• Radiation therapy: Radiation therapy uses high-powered energy beams to destroy cancer cells and shrink tumors. Radiation may come from a machine outside the body or from radiation-containing materials inserted into the liver. Radiation may be used on its own to treat localized unresectable cancer. Individuals may have radiation therapy following surgical removal of a tumor to help destroy any remaining malignant cells. Radiation side effects may include fatigue, nausea, vomiting, and hair loss.

• Chemotherapy: Chemotherapy uses prescription drugs to kill cancer cells. Chemotherapy drugs used to combat liver cancer can be delivered to the whole body or to a specific location, leading to cancer cell destruction. Chemotherapy is usually given via a vein. Some individuals have an infusion pump placed under the skin of the abdomen to deliver chemotherapy directly to the liver. The infusion pump can be refilled with drugs as needed.

• Chemotherapy side effects may include: temporary hair loss; mouth sores; and anemia or a decreased number of red blood cells. Anemia may cause fatigue, dizziness, shortness of breath, and leukopenia or a decreased numbers of white blood cells. Leukopenia may lower resistance to infection. Other side effects of chemotherapy may include thrombocytopenia or a decreased number of platelets and gastrointestinal symptoms, including nausea, vomiting, and diarrhea.

• Liver transplant: When the liver has been severely damaged, a liver transplant may be the only treatment option. Liver transplants have been increasingly successful. However, there are not enough donor organs available for every patient who needs a transplant, and not all patients are suitable transplant candidates. It is estimated that more than 10,000 living donor transplants have been performed worldwide, and that the recipient death rate is approximately 9%.

Integrative Therapies

• Good scientific evidence:

• Cordyceps: In traditional Chinese medicine, cordyceps has been used to support and improve liver function. Cordyceps may stimulate the immune system and improve serum gamma globulin levels in hepatitis B patients. Currently, there is insufficient evidence to recommend for or against the use of cordyceps for chronic hepatitis B. However, early study results are promising. Additional research of cordyceps and current hepatitis treatments is needed.

• Avoid if allergic or hypersensitive to cordyceps, mold or fungi. Use cautiously with diabetes, bleeding disorders or taking anticoagulant medications, with prostate conditions, if taking immunosuppressive medications, or if on hormonal replacement therapy or oral contraceptives. Avoid with myelogenous type cancers. Avoid if pregnant or breastfeeding.

• 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.

• Milk thistle: Multiple studies from Europe suggest benefits of oral milk thistle for cirrhosis. In experiments up to five years long, milk thistle has improved liver function and decreased the number of deaths that occur in cirrhotic patients. Although these results are promising, most studies have been poorly designed. Further research is necessary before a strong recommendation can be made.

• In addition, several studies of oral milk thistle for chronic hepatitis caused by viruses or alcohol report improvements in liver tests. However, most studies have been small and poorly designed. More research is needed before a recommendation can be made.

• Use cautiously if allergic to plants in the aster family (Compositea, Asteraceae), daisies, artichoke, common thistle, or kiwi. Use cautiously with diabetes. Avoid if pregnant or breastfeeding.

• Probiotics: Liver cirrhosis may be accompanied by an imbalance of intestinal bacteria flora. Probiotic supplementation in cirrhosis patients has been found to reduce the level of fecal acidity (pH) and fecal and blood ammonia, which are beneficial changes.

• Probiotics are generally considered safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.

• 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.

• Alpha-lipoic acid: Alpha-lipoic acid (ALA) has been studied as a treatment for alcoholic liver disease. However, benefits have not been observed at this time. More research is needed in this area.

• Avoid if allergic to ALA. Use cautiously with diabetes and thyroid diseases. Avoid with thiamine deficiency or alcoholism. Avoid if pregnant or breastfeeding.

• 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.

• 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.

• Anti-viral activity has been reported with the use of astragalus in laboratory and animal studies. Limited human and animal research has examined the use of astragalus for viral infections in the liver (hepatitis B and C). However, most studies have been small and poorly designed. Due to a lack of well-designed research, no firm conclusions can be drawn. Clinical data suggests that astragalus may be effective in treating cirrhosis. Further research is needed to better understand the use of astragalus for liver protection.

• 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.

• Ayurveda: Ayurveda is an integrated system of specific theories and techniques employing diet, herbs, exercise, meditation, yoga and massage or bodywork. Clinical evidence suggests that the traditional herbal preparation Kamalahar may reduce clinical signs as well as indicators of liver damage in acute viral hepatitis. Kamalahar contains Tecoma undulate, Phyllanthus urinaria, Embelia ribes, Taraxacum officinale, Nyctanthes arbortistis, and Terminalia arjuna. The root powder from the herb Picrorhiza kurroa has also been shown to improve levels of bilirubin, SGOT (serum glutamic-oxaloacetic transaminase) and serum glutamic pyruvic transaminase (SGPT) in viral hepatitis. Further research is needed before a firm conclusion can be made.

• Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking.

• 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.

• Biotin: Biotin is an essential water-soluble B vitamin. Antioxidant therapy with biotin, vitamins A-E, selenium, zinc, manganese, copper, magnesium, folic acid, and coenzyme Q10 was not shown to improve survival rates for hepatitis. More research with biotin alone is needed. Avoid if hypersensitive to constituents of biotin supplements.

• 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 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.

• Bupleurum: For more than 2,000 years bupleurum has been used in Asia to treat hepatitis, cirrhosis and other conditions associated with inflammation. A high-quality clinical trial and several small recent clinical reports suggest that bupleurum and/or an herbal combination formula containing bupleurum may be helpful in the treatment of chronic hepatitis. However, studies to date are small and not all well controlled. Further research is warranted to determine whether bupleurum can effectively treat hepatitis.

• Avoid if allergic or hypersensitive to bupleurum, Apiaceae or Umbelliferae (carrot) families, snakeroot, cow parsnip, or poison hemlock. Use cautiously if operating motor vehicles or hazardous machinery. Use cautiously with low blood pressure, diabetes, or edema. Use cautiously with a history of bleeding, hemostatic disorders, or drug-related hemostatic disorders. Use cautiously if taking blood thinners. Avoid if pregnant or breastfeeding.

• Capers: There is limited evidence of the effect of capers alone on cirrhosis. Additional studies are needed.

• Capers are generally considered to be safe. Avoid with allergy or sensitivity to capers or mustard oil. There are limited reports of side effects with capers. Use cautiously with diabetes or low blood sugar or in those taking drugs, herbs, or supplements that lower blood sugar. Use cautiously with low blood pressure or if taking drugs, herbs, or supplements that lower blood pressure. Use cautiously in patients prone to iron overload. Use cautiously if taking diuretics. Use cautiously if pregnant or breastfeeding.

• 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.

• Chicory: Chicory (Chichorium intybus) has been suggested as a possible treatment for chronic hepatitis. However, further research is needed before a definitive conclusion can be made.

• Avoid if allergic/hypersensitive to chicory or members of the Asteraceae or Compositae family, including ragweed, chrysanthemums, marigolds, and daisies. Use cautiously if taking drugs or herbs metabolized by cytochrome P450 enzymes. Use cautiously with gallstones. 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.

• Chlorophyll may act to improve the detoxification of toxins involved in cancer promotion. However, more research is needed in regard to protection from aflatoxins. It may also inhibit the absorption of dietary heterocyclic aromatic amines, which may act as potential carcinogens. The results of one clinical trial suggest that prophylactic interventions with chlorophyllin or diet supplementation with chlorophyll-rich foods may be a practical means to prevent the development of hepatocellular carcinoma or other environmentally-induced cancers. Additional large scale clinical research is needed in this area before a clinical recommendation can be made.

• 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.

• Choline: Studies have assessed the use of choline for acute viral hepatitis, many of which have been poorly designed. There is currently insufficient evidence available to determine whether choline can effectively treat hepatitis.

• Avoid if allergic/hypersensitive to choline, lecithin, or phosphatidylcholine. Use cautiously with kidney or liver disorders or trimethylaminuria. Use cautiously with a history of depression. If pregnant or breastfeeding it seems generally safe to consume choline within the recommended adequate intake (AI) parameters; supplementation outside of dietary intake is usually not necessary if a healthy diet is consumed.

• 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.

• Clay: Phyllosilicate clay has been shown to adhere to aflatoxins in laboratory study, and HSACS clay in animal diets may diminish or block exposure to aflatoxins. However, the risks of chronic clay exposure likely do not justify the potential benefit of protection from aflatoxins.

• There is a lack of reports of allergy to clay in the available scientific literature. However, in theory, allergy/hypersensitivity to clay, clay products, or constituents of clay may occur. 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.

• 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.

• Cordyceps: In traditional Chinese medicine, cordyceps has been used to support and improve liver function. In two studies using herbal combinations that included cordyceps, liver and immune function were improved. However, as these studies used combination treatments, the effect of cordyceps alone for treatment of cirrhosis is currently unknown.

• Avoid if allergic or hypersensitive to cordyceps, mold or fungi. Use cautiously with diabetes, bleeding disorders or taking anticoagulant medications, with prostate conditions, if taking immunosuppressive medications, or if on hormonal replacement therapy or oral contraceptives. Avoid with myelogenous type cancers. Avoid if pregnant or breastfeeding.

• 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.

• Human study reports improved liver function in patients with chronic hepatitis B after taking a combination herbal preparation containing dandelion root, called Jiedu Yanggan Gao (also including Artemisia capillaris, Taraxacum mongolicum, Plantago seed, Cephalanoplos segetum, Hedyotis diffusa, Flos chrysanthemi indici, Smilax glabra, Astragalus membranaceus, Salviae miltiorrhizae, Fructus polygonii orientalis, Radix paeoniae alba, and Polygonatum sibiricum). Because multiple herbs were used the effects of dandelion are unclear.

• 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.

• Danshen: Some studies suggest that danshen may provide benefits for treating liver diseases such as cirrhosis, fibrosis and hepatitis B. However, it is unclear whether there are any clinically significant effects of danshen in patients with these conditions.

• Avoid if allergic or hypersensitive to danshen. Use cautiously with altered immune states, arrhythmia, compromised liver function or a history of glaucoma, stroke, or ulcers. 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 taking blood thinners (anticoagulants), digoxin or hypotensives including ACE inhibitors such as captopril, or Sophora subprostrata root or herba serissae. Avoid with bleeding disorders, low blood pressure and following cerebal ischemia. 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.

• Eyebright: Limited evidence from animal studies suggests that aucubin, a constituent of eyebright, may inhibit hepatic RNA and protein syntheses in vivo. These properties have been associated with protective effects in carbon tetrachloride and alpha-amanitin-induced hepatotoxicity in mice. Conversion of aucubin to its algycone appears to be a prerequisite step for these hepatic effects to occur. The clinical relevance of these finding to humans is unclear, and there is currently insufficient evidence to determine whether eyebright is an effective agent for hepatoprotection.

• Avoid if allergic to eyebright, any of its constituents, or members of the Scrophulariaceae family. Use cautiously with diabetes and drugs that are broken down by the liver. Avoid if pregnant or breastfeeding.

• 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.

• Germanium: There is limited evidence for the use of propagermanium (an organogermanium) in the treatment of hepatitis B. Additional research is warranted in this area.

• Avoid if allergic or hypersensitive to germanium, its compounds or germanium-containing plants. Avoid if pregnant or breastfeeding.

• 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.

• There is currently a lack of sufficient evidence to recommend either American ginseng or Panax ginseng as an agent for hepatoprotection. Laboratory study investigated compound K, a ginseng metabolite that shows promise in protecting against liver injury. Additional human studies are warranted in this area. Early studies show that ginseng may improve some aspects of liver function but not others. More research is needed regarding chronic hepatitis B.

• 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.

• Gotu kola: Study results of gotu kola (Centella asiatica) for liver disease are mixed. Further research is needed before a recommendation can be made for liver cirrhosis.

• Avoid if allergic to gotu kola, asiaticoside, asiatic acid, or madecassic acid. Avoid with a history of high cholesterol, cancer, or diabetes. Avoid if pregnant or breastfeeding.

• 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.

• Jiaogulan extract may be helpful for those with nonalcoholic fatty liver disease when combined with other treatment. More research is needed.

• 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.

• Lactobacillus acidophilus: Lactobacilli are bacteria that normally live in the human small intestine and vagina. There is limited study in individuals with hepatic encephalopathy (confused thinking due to liver disorders), and more studies need to be performed in this area.

• Acidophilus may be difficult to tolerate if allergic to dairy products containing L. acidophilus. Avoid with history of an injury or illness of the intestinal wall, immune-disease, or heart valve surgery. Avoid with prescription drugs, like corticosteroids, because of the risk of infection. Use cautiously with heart murmurs. Antibiotics or alcohol may destroy Lactobacillus acidophilus. Therefore, it is recommended that Lactobacillus acidophilus be taken three hours after taking antibiotics or drinking alcohol. Some individuals can use antacids (like famotidine (Pepcid®), esomeprazole (Nexium®)) to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.

• 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.

• L-carnitine: Although early evidence suggests that L-carnitine may effectively treat cirrhosis, further research is needed to confirm these results. Preliminary evidence also suggests that L-carnitine may be of benefit to individuals with hepatic encephalopathy, in terms of ammonia levels and psychometric functioning. Additional study is needed.

• Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

• Licorice: The licorice extracts DGL and carbenoxolone have been proposed as possible therapies for viral hepatitis. Further research is needed before a firm conclusion can be made.

• Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or if taking diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.

• Liver extract: Liver extract seems to stimulate liver function and may be of benefit in treatment of hepatic disorders such as chronic hepatitis. More research is needed to compare liver extract to other hepatostimulatory treatments.

• Avoid if allergic or hypersensitive to liver extract or its constituents. Use cautiously if taking antacids or with acid reflux. Use cautiously with clotting disorders, compromised immune function, and abnormal iron levels. Use cautiously if taking antihypercholesterolemic drugs (drugs that affect blood cholesterol), antiviral agents, especially interferon, or any agents for cancer. Use cautiously as raw liver may contain liver flukes or the bacterium, Vibrio fetus. Use cautiously in hepatopathic patients with reduced human growth hormone metabolic clearance rate. Avoid liver extract with iron metabolism disorders or iron shortage disorders, such as hemochromatosis. Avoid liver extract from countries where bovine spongiform encephalitis (BSE or "mad cow disease") has been reported. Avoid if sensitive to liver extract or any of its components, as liver extract therapy has caused severe anaphylactic shock. 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 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.

• Several clinical studies suggest possible benefits of milk thistle to treat or prevent drug or toxin induced hepatotoxicity. Results of this research are not clear, and most studies have been poorly designed. More research needs to be performed in this area. Milk thistle has been used traditionally to treat Amanita phalloides mushroom toxicity and poisoning. However, there are not enough reliable studies in humans to support this use of milk thistle. Research on milk thistle for acute viral hepatitis has not provided clear results, and milk thistle cannot be recommended for this potentially life-threatening condition at this time.

• 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.

• In preliminary research, some patients achieved complete elimination of the hepatitis virus after treatment with Viscum album, although these studies were not well designed. A small exploratory trial investigated effects of mistletoe on liver function, reduction of viral load and inflammation, and maintaining quality of life by the immunomodulatory and/or cytotoxic actions of mistletoe extracts, but little effect was seen. Larger, well-designed clinical trials are needed to resolve this conflicting data.

• 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.

• Peony: The peony species Paeonia lactiflora Pallas has been used in traditional Chinese medicine (TCM) to treat liver disease. In humans, Paeonia rubra root has been given to patients with liver cirrhosis. Larger controlled trials of higher methodological quality are necessary to substantiate the positive results of this small case series.

• Avoid if allergic or sensitive to peony. Avoid with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.

• 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.

• 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.

• Probiotics: Initial studies of probiotics for minimal hepatic encephalopathy (confused thinking due to liver disorders) are encouraging. Probiotics and probiotics may lead to the improvement of symptoms and may be an alternative to lactulose for the management of this condition in people with cirrhosis. However, more studies are needed to determine the role of probiotics in this condition.

• Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.

• PSK: PSK, or protein-bound polysaccharide, is obtained from cultured mycelia of the Coriolus versicolor, a mushroom thought to have antimicrobial, antiviral, and antitumor properties. Studies of PSK as a therapy for liver cancer have yielded mixed results. Well-designed clinical trials are needed to determine the role of PSK on survival time and remission in patients with liver cancer.

• PSK generally seems to have a low incidence of mild and tolerable side effects. In one report, three cases of toxicity were noted, and PSK was discontinued. PSK has been associated with side effects of gastrointestinal upsetand darkening of the fingernails, but these effects have been limited and general safety has been demonstrated with daily oral doses for extended periods. Darkening of the fingernails and coughing have been reported during administration of the powdered form of PSK.

• 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.

• Based on positive laboratory evidence, a clinical trial using Ganopoly® or placebo was conducted in chronic hepatitis B patients. Ganopoly® treatment decreased levels of hepatitis B virus (HBV) DNA. Further well-designed research is needed before a firm conclusion can be made.

• 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.

• Rhubarb: Two studies have been conducted on rhubarb and its effects on hepatitis. In the case series, high doses of rhubarb decreased the symptoms and serum levels associated with hepatitis. However, additional, high-quality studies are needed to establish rhubarb's effects.

• Avoid if allergic/hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, pre-eclampsia, renal disorders, ulcerative colitis, and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12 due to water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking anti-psychotic drugs or oral drugs, herbs or supplements (including calcium, iron, and zinc). Avoid if pregnant or breastfeeding.

• Safflower: EH0202 is a traditional Japanese Kampo therapy containing safflower seed extract and is used for immunostimulation. More studies with safflower alone are needed to better define safflower's effect on chronic hepatitis.

• Avoid if allergic/hypersensitive to safflower, Carthamus tinctorius, safflower oil, daisies, ragweed, chrysanthemums, marigolds, or any related constituents. Use parenteral safflower oil emulsions cautiously in newborns. Use cautiously if taking anticoagulants (blood thinners) or anti-platelet drugs, immunodepressants, or pentobarbital. Use cautiously with diabetes, hypotension, inadequate liver function, hypercoagulability, and skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.

• SAMe: Preliminary evidence from meta-analyses and randomized clinical trials suggests that SAMe may normalize levels of liver enzymes in individuals with liver disease. Well-designed clinical trials, with appropriate subject number in homogenous populations are required before a definitive conclusion can be made.

• Avoid if allergic or hypersensitive to SAMe. Use cautiously with diabetes and anxiety disorders, or women in their third trimester of pregnancy. Avoid with bipolar disorder. Avoid during the first trimester of pregnancy or if breastfeeding.

• Schisandra: The efficacy of schisandra as a hepatoprotective agent has been demonstrated in multiple studies. Based on these observations, schisandra has been suggested as a potential treatment for liver disease. Future studies are warranted to assess the long-term efficacy and safety of schisandra compared to standard therapies.

• Use cautiously during pregnancy or lactation or in patients with bleeding disorders, seizure disorders, high intracranial pressure, high blood pressure, skin diseases, gastoeseophageal reflux or peptic ulcer disease, neurological disorders, or diabetes. Avoid in patients allergic to schisandra, any of its constituents, or other members of the Schisandraceae family. Allergic skin rashes and urticaria has been reported in some patients.

• Sea buckthorn: Sea buckthorn extract may improve liver health in people with cirrhosis. Although the results are intriguing, additional higher quality research is needed in this area.

• Avoid if allergic or hypersensitive to sea buckthorn, its constituents, or members of the Elaeagnaceae family. Use cautiously if taking angiotensin converting enzyme (ACE) inhibitors, anticoagulants and antiplatelet agents (blood thinners), antineoplastics (anticancer agents), or cyclophosphamide or farmorubicin. Avoid higher doses than food amounts 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.

• Selenium supplementation has been studied in various liver disorders, including hepatitis, with mixed results. Further research is needed to establish selenium's effects on liver disease.

• 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.

• 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.

• Taurine: Early studies have found that taurine supplementation has the potential to modify the conjugation of bile acids, potentially modifying the disease. Furthermore, taurine has been examined as an adjunct to ursodeoxycholate (UDCA) in the treatment of liver disease. Results from these early studies suggest that conjugation of bile acids can be modified and that taurine as an adjunct to UDCA does not offer more benefits. More recent studies are investigating the effect of tauroursodeoxycholate (TUDCA) in liver disease treatment. As of yet, however, the evidence in support of taurine in liver disease is minimal and well-designed clinical trials with positive results are needed before a firm conclusion can be made.

• Taurine is an amino acid and it is unlikely that there are allergies related to this constituent. However, allergies may occur from multi-ingredient products that contain taurine. Use cautiously in patients with high cholesterol, low blood pressure, coagulation disorders, potential for mania, or epilepsy. Avoid consuming alcohol or exercising after consumption of energy drinks containing taurine, caffeine, glucuronolactone, B vitamins, and other ingredients. Use cautiously if pregnant or breastfeeding because taurine is a natural component of breast milk.

• 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.

• Preliminary evidence suggests that thymus extract may offer benefit to individuals with liver disease. More well-designed clinical trials are required.

• 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.

• TCM may also provide protection for liver disease. However, more studies are needed before recommendations can be made.

• 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.

• In traditional Indian Ayurvedic medicine, turmeric has been used to tone the liver. Early research suggests that turmeric may have a protective effect on the liver. More research is needed to better determine the effectiveness of turmeric for hepatoprotection.

• 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 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.

• 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.

• In patients with hepatitis on antiviral therapy, vitamin E has been proposed to prevent inflammation. More studies are needed. There is also preliminary evidence suggesting possible benefits of vitamin E in the management of steatohepatitis in children, although further evidence is necessary before a clear conclusion can be drawn.

• 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.

• Zinc: Zinc is necessary for the functioning of over 300 different enzymes and plays a vital role in an enormous number of biological processes. People with alcoholic liver cirrhosis may be deficient in zinc. Preliminary studies suggest that zinc may benefit these patients. Further evidence is needed to confirm these findings. Studies have shown that zinc, in combination with interferon or interferon and ribavirin for chronic hepatitis C viral infection, did not show significant benefits except for lower incidence of gastrointestinal side effects. Further study may be warranted. Early human trials of zinc for hepatic encephalopathy have yielded conflicting results.

• Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used since studies cannot rule out the possibility of harm to the fetus.

• 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.

• Spirulina: Despite findings indicating potential hepatoprotective properties of spirulina, preliminary human study of spirulina for chronic viral hepatitis shows negative results. Additional high quality study is needed to confirm these findings.

• Avoid if allergic or hypersensitive to spirulina or blue-green algae. Use cautiously with phenylketonuria (a genetic disorder of a liver enzyme that disrupts normal body functions), autoimmune diseases, bleeding disorders, diabetes, and osteoporosis. Use cautiously with products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp.; in underweight patients or in those taking antiobesity agents or appetite suppressants; and if consuming a high-protein diet. Avoid in children and if pregnant or breastfeeding.

• Urine therapy: There is currently insufficient evidence from clinical studies to support the use of urine or urea in the treatment of liver cancer. Additional studies are needed to make a firm recommendation.

• Use cautiously in children, if taking medications, especially antidepressants, antipsychotics and/or sedative/hypnotic agents, or with gastrointestinal problems. Avoid with urinary tract or kidney infection or if pregnant or breastfeeding. Avoid if allergic or hypersensitive to urine or any of its metabolites.

• 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.

• Vitamin K: Infection with the hepatitis C virus (HCV) may lead to hepatocellular carcinoma, a form of liver cancer. So far, the results from clinical studies are unclear and do not indicate any beneficial effects of vitamin K in the recurrence of hepatocellular carcinoma.

• Avoid if allergic or hypersensitive to vitamin K. Injection into the muscle or vein should only be done by a healthcare professional; many serious side effects have occurred after injection. Menadiol (a type of vitamin K that is not available in the United States) should be avoided with glucose-6-phosphate dehydrogenase deficiency. Conditions that interfere with absorption of ingested vitamin K may lead to deficiency, including short gut, cystic fibrosis, malabsorption (various causes), pancreas or gall bladder disease, persistent diarrhea, sprue, or ulcerative colitis. Avoid if pregnant. Use cautiously if breastfeeding.

Prevention

• Hepatitis risk reduction: Individuals at risk for liver cancer can greatly reduce their risk of developing liver cancer by taking steps to be protected from hepatitis B and C, cirrhosis, and other liver diseases.

• The most effective way to prevent hepatitis B is to receive the hepatitis B vaccine, which provides more than 90% protection for both adults and children. Protection lasts years and possibly for life. The vaccine can be given to almost anyone, including infants, older adults, and those with compromised immune systems, such as with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Infants often receive the vaccine in the first year of life. Typically, hepatitis vaccines are given at two, four, and nine months of age.

• No vaccination exists for hepatitis C (HCV). However, there are measures to follow that can play a key role in protecting against hepatitis C infection. Hepatitis C can be transmitted through body fluids, such as sexually or intravenous (IV) needle use. It is recommended by healthcare professionals to not engage in unprotected sex unless absolutely certain the partner is not infected with HBV, HCV, or any other sexually transmitted diseases. If the health status of a partner is not known, using a latex condom is recommended. The best way to protect against HCV is not to inject drugs. But if that is not an option for the individual, making sure any needle used is sterile is very important. It is also important not to share needles. Contaminated drug paraphernalia is responsible for about half of all new HCV cases. Community needle exchange programs are available in most urban areas. It is best to avoid body piercing and tattooing. Needles that may not be properly sterilized can spread the virus.

• Limiting alcohol consumption: If an individual has liver disease, such as cirrhosis, consuming any amount of alcohol can be dangerous. Consuming moderate to heavy amounts of alcohol, such as more than one drink a day for women and more than two for men, may increase the risk of developing certain cancers. This is particularly true if the individual has a close relative, such as a parent, child, or sibling with cancer.

• Avoiding liver metabolized medications: Certain medications that are metabolized in the liver can also damage the liver. A doctor or pharmacist can advise individuals about these medications, which may include over-the-counter (OTC) medications, such as acetaminophen (Tylenol®), as well as many prescription drugs. It is recommended by healthcare professionals to avoid mixing alcohol and acetaminophen (Tylenol®).

• Chemical exposure reduction: Chemical toxins are metabolized in the liver. If the individual works with chemicals, such as in the cases of hairdressers, printers, and painters, they should follow all safety instructions to avoid exposure. If an individual has their own well for water, they may wish to have it tested for contaminants such as lead and arsenic. Local health departments can be a source of water testing.

• Exercise and weight control: Controlling weight and exercising regularly can reduce the risk of developing cancer. The American Cancer Society recommends at least 30 minutes of physical activity five or more days a week if the individual can tolerate it.

• Fruits, vegetables and whole grains: Fruits, vegetables, and whole grains contain vitamins, minerals, fiber, and antioxidants, which may help prevent various types of cancer. Eating five or more servings of fresh fruits and vegetables every day is important for health. A variety of produce should be included in the individual's diet such as kale, chard, spinach, dark green lettuce, peppers, and squashes.

• Smoking cessation: Smoking can increase the risk of cancers.

• Vitamins and minerals: Calcium, magnesium, pyridoxine (vitamin B6), and folic acid may help reduce the risk of certain cancers. Good food sources of calcium include skim or low-fat milk and other dairy products, shrimp, and soy products such as tofu and soy milk. Magnesium is found in leafy greens, nuts, peas, and beans. Food sources of vitamin B6 include grains, legumes, peas, spinach, carrots, potatoes, dairy foods, and meat. Folic acid is found in dark leafy greens such as spinach and lettuce, and in legumes, melons, bananas, broccoli, and orange juice.

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.

1. American Academy of Family Physicians. http://familydoctor.org.

2. American Cancer Society. www.cancer.org.

3. American Gastroenterological Association. www.gastro.org.

4. American Liver Foundation. www.liverfoundation.org.

5. Centers for Disease Control and Prevention (CDC) www.cdc.gov.

6. Hashimoto K, Ikeda Y, Korenaga D, et al. Ten-year survival of patients with hepatocellular carcinoma after hepatectomy. Hepatogastroenterology. 2007 Jan-Feb;54(73):163-6. View Abstract

7. Lai MS, Hsieh MS, Chiu YH, et al. Type 2 diabetes and hepatocellular carcinoma: A cohort study in high prevalence area of hepatitis virus infection. Hepatology. 2006 Jun;43(6):1295-302. View Abstract

8. National Cancer Institute. www.cancer.gov.

9. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

10. Rougier P, Mitry E, Barbare JC, et al. Hepatocellular carcinoma (HCC): an update. Semin Oncol. 2007 Apr;34(2 Suppl 1):S12-20. View Abstract

11. Talamini R, Polesel J, Montella M, et al. Food groups and risk of hepatocellular carcinoma: A multicenter case-control study in Italy. Int J Cancer. 2006 Dec 15;119(12):2916-21. View Abstract

12. Voigt MD. Alcohol in hepatocellular cancer. Clin Liver Dis. 2005 Feb;9(1):151-69. View Abstract