July 2007: Vitamins and Herbal Supplements

Healthy vitamin regimen for survivors?

Question from Bright Eyes: I am a 15-year survivor of breast cancer. I am now 49 years old and would like to know what a general, overall healthy vitamin regimen would be.

Answers —Beth DuPree, M.D., F.A.C.S.: As a woman who is either in menopause or near menopause, there are several things that you need to consider when looking at what you can do to improve your overall health, and vitamin supplements are just part of the process. The first thing that you need to consider is what a healthy weight is for your body size, as extra body fat can be a potential source of estrogen and therefore that would be the first starting point in developing a plan for your overall health and wellness. When it comes to a vitamin supplement, I recommend that my patients who are nearing menopause take a basic vitamin supplement such as a Women's One-A-Day vitamin and since you have had cancer, there are several vitamins that have very high antioxidant potential that should be included. Among those, Vitamins A, E, and C. Selenium, zinc, and CoQ-10 are very important factors. These are found naturally occurring in many foods but to obtain the vitamin amounts that you need to be effective, eating those amounts of food would be prohibitive. The important thing to remember when taking antioxidant supplements is to discuss this with your physician, as many agents we use to treat cancer can be counteracted by the strong antioxidants. Since it has been 15 years since your diagnosis, this should not be an issue. The calcium supplementation is also very important as your bones are nearing the point where osteoporosis and bone mineral loss may begin to be seen. The other factor that you need to add at your age is regular exercise with strength training, as this can help to rebuild bone mineral loss and help prevent osteoporosis. The Vitamin D should be included in the regular One-A-Day vitamin.

Gary Deng, M.D., Ph.D.: The best way to get some of these micronutrients is by a balanced diet. Don't think a vitamin regimen is a replacement for that kind of dietary plan. So pay primary attention to the food you're eating instead of supplements.

No copper or iron for cancer?

Question from Mesquite: Is it true that people who have been diagnosed with cancer should not take multivitamins with copper and iron? I am a 53 year-old woman in menopause.

Answer —Gary Deng, M.D., Ph.D.: I think there are theories out there that claim that iron is not good for cancer patients. One theory is copper stimulates the growth of blood vessels. Based on what we know now, the amount of iron in a regular strength multivitamin is not high enough to cause any significant problem. I do not think people need to avoid vitamins that contain those two elements. On the other hand, too much of them may be harmful. So do not take extra supplementations than those in the multivitamin, unless there's a strong indication, for example, that you have iron deficient anemia. Then you need to take extra iron supplementation.

Vitamin B, magnesium affect neuropathy?

Question from Hurting in PA: I have really bad neuropathy in both legs and fingertips from Taxol. Should my Vitamin B and magnesium levels be checked? I have also heard too much Vitamin B can cause neuropathy.

Answers —Beth DuPree, M.D., F.A.C.S.: Number one, unfortunately peripheral neuropathy is a side effect from Taxol (chemical name: paclitaxel) that many patients suffer from. In most cases, the neuropathy improves significantly as the time from treatment lengthens. I do not think that checking levels of Vitamin B and magnesium will in any way be able to help with that neuropathy. If it has been more than six months since the chemotherapy is completed and the symptoms persist, you may want to consider trying a complementary modality such as acupuncture to help treat those symptoms. I do have an occasional patient who has long-term neuropathy from the chemotherapy and I always remember to remind them that everything in life has side effects and potential risks. It's the risk that not having the Taxol therapy potentially would have increased the risk of the cancer spreading elsewhere in the body; therefore, sometimes we need to accept the long term side effects of the chemotherapy as we gain the benefit of a body that no longer has viable cancer cells within it.

Gary Deng, M.D., Ph.D.: I don't think that checking the Vitamin B and magnesium levels would be helpful either.

Natural supplement for tamoxifen?

Question from Joanne: I've decided not to take tamoxifen since my DCIS is low grade and I do not like the side effects I have been reading about. Is there any natural supplement you could recommend that might help reduce the risk of recurrence of DCIS?

Answer —Beth DuPree, M.D., F.A.C.S.: Joanne, many patients do not want to risk the side effects of tamoxifen or other anti-estrogen agents. There are no naturally occurring substances that have specific anti-estrogen effects but the best way for you to decrease the circulating estrogen in your body is to become as physically healthy as you possibly can by decreasing your body fat content through a healthy diet, regular exercise, and strength training. What many people do not realize is that the drug tamoxifen and the second generation anti-estrogen medications such as Arimidex (chemical name: anastrozole) and Femara (chemical name: letrozole) work by decreasing the effective circulating estrogen in the body. Our natural means of decreasing the circulating estrogen in our body can come by (1) the removal of the ovaries surgically, or (2) the lack of function of the ovaries through menopause and (3) the method that requires the most intense work is by obtaining a physically fit body that is low in fat content and high in muscle content. In other words, a lean physique, thereby decreasing the body's ability to make estradiol through the conversion of fats to estrogen in the adrenal glands.

Best herbs, vitamins for immune system?

Question from Eva: What are the best herbs and vitamins to boost the immune system?

Answer —Gary Deng, M.D., Ph.D.: First of all, boosting the immune system may not always be a good thing, for example, in people with autoimmune diseases or diseases with an autoimmune component such as rheumatoid arthritis, hyperthyroidism, and several other diseases. In those people, an overactive immune system may make the disease worse. Secondly, most of the herbs or supplements that have shown to "boost the immune system" have been studied mainly in laboratory studies or animal studies. Whether they do the same thing in humans is still being investigated. So at this point, we cannot really say there is a best herb or supplement that boosts the immune system. However, there are other things that people can do to foster a healthy and strong immune system, such as make sure they are not malnourished. For people who are protein-deficient, their immune systems are severely weakened. They should also make sure they reduce the stressors in their lives, as stress raises the level of stress hormones, which are immunosuppressants. So unfortunately I cannot say there is one best herb that will boost the immune system, but there are many herbal supplements that have this potential. Many research groups are studying them to see how we can use them in the most appropriate way to benefit patients.

Vitamins, black cohosh for hot flashes?

Question from Debbie: My oncologist suggested 800 IU Vitamin E, 500 mg Vitamin C, B-complex and black cohosh for hot flashes and night sweats. Is there any validity to this?

Answer —Gary Deng, M.D., Ph.D.: This is a combination of several supplements that in some clinical studies has shown some efficacy in reduction of hot flashes. On the other hand, there are also studies of the same agents that did not show efficacy. So at this point, we don't know for sure that they're going to help you. But if the hot flashes are causing a major problem in your quality of life, you can try them. At this dose, they are generally safe. One thing you may want to keep in mind is for people with heart problems, taking more than 400 I.U. of Vitamin E for a prolonged period of time has been associated with some problems with peoples' hearts.

Antioxidants harmful for cancer?

Question from Dimacken: I am currently undergoing radiation and wanted to start taking antioxidants but have recently read that they may be more harmful to you if you already have cancer. Is this true? If so what would be more beneficial to take?

Answer —Beth DuPree, M.D., F.A.C.S.: Radiation therapy is a treatment modality that works by killing rapidly dividing cells and this occurs through the formation of free radicals. Antioxidants' role in cancer prevention is to prevent the formation of free radicals which can induce a potential cancer from beginning. Therefore we typically use antioxidants to prevent bad free radicals from forming, but during radiation therapy we use the free radicals to kill the rapidly dividing cells, such as treating fire with fire. Therefore the antioxidants during radiation could have a negative effect or counteract the effect of the radiation therapy and this would not be good. This is also true for certain types of chemotherapeutic agents such as Adriamycin-based regimens so it is incredibly important that every patient discuss whatever supplements they are taking with their treating physician.

B12 okay while getting chemo?

Question from Dorothy: I usually take B12 while getting chemo. Should I continue?

Answer —Gary Deng, M.D., Ph.D.: In most people who are not Vitamin B12 deficient, there is no need to have B12 injections. If you are taking B12 orally, it is OK. I do not see any problem with chemotherapy.

Supplements for chemo brain?

Question from Terri: Is there any supplement that has helped with symptoms of "chemo brain"?

Answer —Gary Deng, M.D., Ph.D.: Chemo brain is a problem people just realized in recent years, so there has not been much research on supplements that can improve the cognitive function of people with chemo brain. There are some supplements that may nurture nerve cells which some people think may help chemo brain such as phosphatidyl. There are people who think gingko may also help, but most research on gingko was done in Alzheimer's patients, not patients with chemo brain. The risk of gingko is it makes blood flow better, so for some people it may raise the risk of bleeding.

Vitamin C not recommended for survivors?

Question from Hager: I've recently heard that Vitamin C isn't good for women who have had breast cancer. So much so that my friend's oncologist recommends that she doesn't take it at all. Should I worry about taking it?

Answer —Gary Deng, M.D., Ph.D.: Vitamin C was used initially for cancer prevention. Several large-scale clinical trials have tested the potential in cancer prevention. Unfortunately, none of those trials showed a benefit. There are people who did laboratory research showing certain cancer cells appeared to require Vitamin C to thrive. Hence the caution that Vitamin C may not be good for cancer patients. My opinion is that a moderate amount of Vitamin C is helpful, but I do not recommend taking excessive amounts of Vitamin C. By "excessive," I mean more than 2 grams per day. At this point, we do not know for sure whether Vitamin C would help or hurt cancer patients, so a moderate amount of Vitamin C intake appears to be the safest way at this point.

Beta carotene helps slow cancer?

Question from Key: I have mets to my lungs. I have heard that beta carotene is good for lung health. Do you think taking this supplement could at least help slow the growth of the cancer? If so, should I take more than the recommended dosage?

Answer —Gary Deng, M.D., Ph.D.: Beta carotene does not help patients with lung metastases. In fact, in a cancer prevention trial involving thousands of people, supplementation of beta carotene was associated with a higher rate of lung cancer in people who are smokers or who quit smoking recently. Therefore, beta carotene cannot be recommended in your case.

Green tea okay with Herceptin?

Question from PMama: Are you aware of a contraindication (or the potential to decrease the effectiveness of treatment) in drinking green tea if you are receiving Herceptin treatments?

Answers —Beth DuPree, M.D., F.A.C.S.: Since green tea is considered to be high in antioxidants, and as we said before, antioxidants help to stop free radical formation, I do not believe that there's any contraindication to drinking green tea during Herceptin treatment, as Herceptin acts by blocking the HER2/neu receptor on the cell surface.

Gary Deng, M.D., Ph.D.: I agree. I do not see any reason green tea would interact with Herceptin in an undesirable way.

Maitake mushrooms for treating breast cancer?

Question from Kkon: Maitake mushrooms are being studied by Sloan-Kettering, I believe. Are there any preliminary results indicating effectiveness in treating breast cancer?

Answer —Gary Deng, M.D., Ph.D.: At Sloan-Kettering we did an early stage study in which we did not look at the efficacy of maitake mushroom extract in treating breast cancer. We gave breast cancer patients different dosages of maitake, and then measured the immunological parameters in their blood, trying to see whether there are any consistent changes that correlate with the amount of maitake the patients were taking. At this point, we are still in the data analysis stage. We have not reached any conclusions yet.

Iscador/Mistletoe for breast cancer treatment?

Question from Cath: Can you please tell us what you know about Iscador/Mistletoe? I was recently told that "Iscador ... (has) been used in Europe since the 1920s and roughly 70 percent of all breast cancers treated in Germany use Iscador as part of their treatment." Please comment.

Answer —Gary Deng, M.D., Ph.D.: These agents have indeed been used for quite a while in Europe. The mechanism appears to be mobilization and stimulation of the immune system when they were given as injections. But I am not aware of any studies that show their efficacy as a sole agent in cancer treatment. In addition, the injectable form is not readily available in this country. There are many similar agents used in other countries for breast cancer or other cancer treatments. Because the criteria to approve these agents differ among the countries, some may be used more widely in one country than another. That by itself does not mean they are definitively helpful. If you want to find more information about these two agents or some of the other herbs or supplements, we have made a web page summarizing the research that has been done on these supplements. You can go to that page at www.mskcc.org/aboutherbs.

Brown seaweed fights off cancer cells?

Question from BriteS: Do you have any information on brown seaweed (algae) such as a product called 'Fucoidan,' which is a potent antioxidant said to be beneficial in fighting off cancer cells? It's popular in Japan.

Answer —Gary Deng, M.D., Ph.D.: The antioxidant effect is not anything special about brown seaweed, because there are so many other things that contain more antioxidant activity. Brown seaweed extract contains mucopolysaccharides which in the laboratory tests have been shown to stimulate certain parts of the immune system. But they do not have a direct effect against cancer cells. Their safety record is pretty good as long as the product is made under good quality control process.

Vitamin or supplement for anemia?

Question from AColling: I finished all of my treatments in Sept. 2006. I am still anemic. Is there a vitamin or supplement that will help?

Answer —Gary Deng, M.D., Ph.D.: The first thing you need to do is to make sure you do not have any easily correctable medical condition that is causing anemia, such as iron deficiency or Vitamin B12 deficiency which, I suppose, your doctor had excluded. After that, there is no supplement that I know of that can stimulate the growth of more red blood cells. There are some herbs used to improve anemia. Some of them may have testosterone or androgen-like activity which we know may stimulate the production of red blood cells. Whether using them is safe in breast cancer patients is unknown, as the metabolism of testosterone sometimes overlaps the metabolism of estrogen. If your anemia is severe, your doctor may give you a shot of growth hormone called Epogen that stimulates the production of red blood cells.

Does anything counteract with Arimidex?

Question from JanM: Are there any vitamins, herbal supplements or foods that counteract with Arimidex? I know grapefruit interfered with tamoxifen.

Answer —Gary Deng, M.D., Ph.D.: Arimidex is in a class of drugs called aromatase inhibitors. Aromatase is an enzyme that is closely related to drug-metabolizing P450 enzyme system in our body. We know several herbs interact with P450 enzyme, the most prominent one being St. John's wort. Therefore, people should avoid herbs that are known to interact with the P450 system.

Familiar with supplements from Mannatech?

Question from KH: Thank you for your time. I wanted to know if you had heard of a supplement company called Mannatech. I have been told by a co-worker that I should look into their products because she has heard some amazing stories by not only cancer patients but people with other health issues. Is this company something legit or a scam? It was featured on 20/20.

Answer —Beth DuPree, M.D., F.A.C.S.: I am not familiar with this company.

How does diet influence recurrence?

Question from CLTann: In today's paper, there is an article about having fruits and vegetables as diet vs. another control group using regular diet. The study result showed no difference in cancer recurrence rate. On the home page of this network, another report shows Chinese women adopting a Western diet have a much higher cancer rate. Who should we listen to?

Answer —Beth DuPree, M.D., F.A.C.S.: The scenario that you have put forth is one of two very different groups being studied. When we look at the incidence of Chinese women adopting a Western diet having an increased cancer rate, there are many factors that come into play. Asian women that move to the U.S. and adopt a higher fat content/lower fruit and vegetable intake have clearly been shown to have an increased risk of developing breast cancer. There are likely several factors that are causing this effect. The first is a diet higher in fat can lead to excessive weight gain and also an increase in circulating estrogen, therefore stimulating cells in the body that, if they have the potential to become cancerous, can do so. The other factors that come into play is that Asian cultures that have very strong meditative practices tend to have a less stressful day-to-day existence, and the adoption of the Western mentality of working to excess at the expense of your spiritual well-being is yet another factor. In the study looking at an article of a diet of fruit and vegetables vs. a regular diet, I would be very interested to know the amount of carbohydrates and other factors in that diet as there is not enough information about those two groups for me to be able to understand what the true difference in those groups are.

Information on goji juice?

Question from Mary: Have you heard of this Himalayan Goji juice? Do you know what it is and if there is anything to the claims made about it?

Answer —Gary Deng, M.D., Ph.D.: Goji fruit is what I call "fruit of the year." Every year there is a new fruit and fruit juice involved. This is one of them. In traditional Chinese medicine, goji berry was used mainly to treat eye problems and liver problems. It was never used for cancer prevention or cancer treatment. So this year it's goji berry; last year it was mangosteen, the year before, pomegranate, and the year before that, noni juice. So I do not think any one of them has a superior effect other than a diverse mixture of all kinds of fruits and berries. In addition, some of the berry juices have added sugar, which is not a good thing.

Curcumin for breast cancer control?

Question from GPonds: Do you have an opinion on taking curcumin? It seems that out of all the herbs, this one has had the most research done on it about breast cancer control.

Answers —Gary Deng, M.D., Ph.D.: Curcumin indeed is one of the herbs that has been studied most extensively. Its major clinical potential is in the prevention of colon polyps and possibly also colon cancer. Research done on breast cancer has been conducted in animal models, where a beneficial effect was observed. The problem with curcumin is the question of bioavailability, meaning how much you have to take to deliver enough curcumin to the cancer tissue. At this point, we do not know that information. Therefore curcumin remains a promising agent; indeed, it is being studied in many laboratories and clinical studies. The risk of curcumin include it may make the blood thinner in people taking blood thinners. Also people with gall bladder problems should not take it.

Beth DuPree, M.D., F.A.C.S.: It can also reduce the effectiveness of certain chemotherapeutic agents such as cyclophosphamide and doxorubicin. So again, please be very open with your physician about any supplements you are taking during treatment.

Melatonin okay through chemotherapy?

Question from Ellie-2: I have heard melatonin is good for cancer and is OK with chemo, but can I take it right through or should I stop a day or two ahead and after?

Answer —Gary Deng, M.D., Ph.D.: Melatonin does not feed cancer or stimulate cancer cells. In Europe, mainly Italy, there are some studies showing it may help during cancer treatment. I do not see any problem in taking it through chemotherapy. But do not use melatonin together with other sleeping pills, especially sedatives, as the additive effect may be too big.

Different supplements for males?

Question from Reefknots: I am a 38-year-old male with breast cancer (mets). Is there any difference in vitamin and other herbal medications for males?

Answer —Gary Deng, M.D., Ph.D.: As far as I know, the effect of herbs or supplements on breast cancers does not depend on the gender of the patient.

Supplements to help regulate pH balance?

Question from Karen: How important is the pH balance in your body, and what if any supplements can help regulate this?

Answers —Beth DuPree, M.D., F.A.C.S.: It is important for the enzymes in your body to function that your body be in balance. There are certain practitioners that believe that by altering the pH of your body, you can help prevent certain disease processes from occurring. But to my knowledge, there are no clinical trials to support changing the pH of your body in order to specifically treat a cancer.

Gary Deng, M.D., Ph.D.: I believe the theory that acidity in the body causes cancer is a faulty one. For example, the most acidic organ in our body is the stomach, which is soaked in acid almost all the time. But stomach cancer is very rare. If acidity causes cancer, we would have seen many more stomach cancer cases. Therefore, I do not think cancer is caused by acidity. Cancer is caused by changes in the DNA of the cells and also the environment around the cells, not simply by acidity.

Which supplements are worthwhile?

Question from Cynic: I have read about various supplements, with and without doctors' names attached to them, that describe remarkable benefits for overall health, and breast cancer specifically. How does someone know what's worthwhile, and what's not?

Answers —Beth DuPree, M.D., F.A.C.S.: This is one of the most difficult areas in healthcare to truly navigate. Because there's no regulation of these supplements, it is hard to know exactly what you're getting for your very hard-earned dollar. There are some physicians who will attach their names to a specific supplement in order to help promote those specific brands, but because the FDA does not regulate the production and manufacturing of these, again it is very hard to know exactly what you are getting from those products. Several years ago, I was approached by a healthcare provider that wanted to attach my name to a set of vitamins in the hope that my thousands of patients would purchase those supplements. But I do not believe that promoting a supplement to my patients is something that I would ever want to be associated with. The recommendations that I make to my patients about diet, vitamins, and antioxidants are general recommendations, not specific brand names or labels.

Gary Deng, M.D., Ph.D.: When choosing a vitamin or supplement, try to rely on information that is based on scientific research, not on personal testimony. There are national level information clearing houses that offer information free of commercial bias. For example, you can go to the web pages of the National Cancer Institute Office of Complementary and Alternative Medicine. Or go to the American Cancer Society, or the National Center for Complementary and Alternative Medicine, or go to MedlinePlus where scientific evidence regarding specific herbs and supplements is presented.

Help to avoid soy, flaxseed for ER+?

Question from CarolC: I have had estrogen-positive breast cancer and must avoid phytoestrogens found in soy, flaxseed and oil of evening primrose. How much of a risk is there in eating foods with soy or flaxseed in them? Almost everything "lite" contains soybean oil or soy lecithin. Everything has soy lecithin or soybean oil in it that I purchase. I take Arimidex daily.

Answer —Beth DuPree, M.D., F.A.C.S.: Unless you are adopting a diet that is so heavily weighted in soy products, I do not believe that you need to worry about the tiny fine print on foods that you are purchasing to eat. The phytoestrogens that are found in soy can have estrogenic effects in the body, but unless you are eating a diet that is so heavily loaded with soy products and soy milk and tofu, etc., I do not think you need to worry about the soy bean oil and lecithin found in the fine print of some of the processed foods. I do not believe that women that have been diagnosed with breast cancer should change their diet to increase the amount of soy in their diet, as the studies involving soy in the diet are very conflicting. Therefore I would not change my diet to increase the soy thinking that you're adding a benefit. But I also would not avoid products in your diet that have soy or lecithin as such minor components.

Supplements for Aromasin pain?

Question from MaryT: Are there any vitamins or herbal supplements that would help the bone and joint pain that is a side effect of Aromasin? Thank you.

Answers —Gary Deng, M.D., Ph.D.: I do not know of any herbs or supplements that may help with joint and bone pain from aromatase inhibitors because we do not know exactly why these patients are having this type of pain, let alone what would counteract that.

Beth DuPree, M.D., F.A.C.S.: In patients that have significant bone and joint pain, I have occasionally found that switching to another aromatase inhibitor may help decrease the side effects. I'm not sure whether this is a placebo effect or if this is truly due to a difference in the drugs, as they all act by the same mechanism

Supplements/herbs for lymphedema?

Question from Summer: Can any supplements/herbs help someone with lymphedema?

Answer —Gary Deng, M.D., Ph.D.: There are none that have been shown to really help lymphedema. There was a report that selenium may prevent lymphedema, but that was an early stage clinical study and whether that is indeed the case would need to be further investigated and confirmed.

Supplements for menopause symptoms?

Question from Brenda-2: What supplements do you recommend for menopause symptoms? Arimidex is really giving me a hard time with hot flashes, vaginal dryness, etc. What do you think about Revival Soy Protein shakes? They contain 160 mg of soy isoflavones. Or something else?

Answer —Beth DuPree, M.D., F.A.C.S.: For women having menopausal symptoms, Effexor can be effective in treating the hot flashes. Also, acupuncture has been shown to be effective in treating hot flashes. In a controlled trial, 85% of women who received acupuncture who had been treated for breast cancer and were on an anti-estrogen medication had significant relief of their hot flashes. As for vaginal dryness, there are over-the-counter personal lubricants such as Astroglide that can help with the day-to-day soreness that comes as a side effect of the anti-estrogen. A decision as to whether or not the vaginal dryness is severe enough to warrant topical or localized estrogen therapy to the vagina is something you should discuss specifically with your breast surgeon, oncologist, and gynecologist.

Where to find guidance on nutrition?

Question from Risa: What qualifications should I look for in someone who will give me nutritional guidance or proven information on vitamins and supplements? It doesn't seem to be an interest of some oncologists.

Answer —Gary Deng, M.D., Ph.D.: Many cancer centers now have a component of integrative medicine. They offer specific advice on nutrition and diet and lifestyle changes that are helpful to breast cancer patients. I suggest you contact a program like this that is close and convenient to you as a starting point.