September 1st, 2015

Is the Best Treatment for Breast Cancer Watchful Waiting?

sailors_stand_in_a_pink_ribbon_formation_at_sea700.Introduction:

A newly published large study indicates the best treatment option for a common form of breast cancer may be no medical treatment. The study examined the results of treatment from over 100,000 women with ductal carcinoma in situ (DCIS), a type of breast cancer where abnormal cells have been found in the lining of the breast milk duct, but the cells are “in situ” meaning that they are in the original place and have not spread.

Women diagnosed with DCIS are routinely told they need to have surgery and begin radiation within two weeks. However, the surprising results from this new study question this conventional wisdom. Aggressive treatment (mastectomy plus radiation) did not lead to a reduction in breast cancer mortality compared to a simple lumpectomy (surgical removal of the small section affected) without radiation.

Treatment with more aggressive surgery and radiation is still appropriate in minority of cases based upon age, race, and/or specific tumor characteristics. In the remaining large majority of women with DCIS, strategies aimed at breast cancer prevention and close observation (also known as watchful waiting) may be the best course of action.

Background Data:

One of the reasons for the recommendation of a yearly screening mammogram has been the assumption that early detection would lead to better treatment outcomes. That recommendation has been challenged by considerable scientific investigation. For example, the Cochrane Collaboration concluded mammography screening overall did not reduce breast cancer mortality and women were ten times more likely to be treated unnecessarily and 200 times more likely to have a false positive finding, causing them undue stress and anxiety. Some reviews have also stated that mammography screening is “no longer effective.” Yet, the American College of Radiology and American Cancer Society recommend yearly screening mammography starting at age 40. So, it remains a controversial subject.

Early treatment of both DCIS as well as early stages of more invasive forms of breast cancer is based upon the thought that earlier treatment would prevent not only recurrence in the same breast, but also early death due to the cancer spreading. However, there are a lot of variables that influence the outcome. In general, results have not supported aggressive treatment for either early stage invasive breast cancer or DCIS. Lumpectomy without radiation is just as effective in terms of survival, as mastectomy with radiation in the overwhelming majority of women. There are exceptions, most notably age of diagnosis (women under 35 generally have more aggressive forms of breast cancer), presence of the breast cancer gene (BRCA), race (black women are at higher risk of having aggressive breast cancer), and the presence of various tumor markers indicative of more aggressive cancer (estrogen-receptor positive, larger tumor, higher replication rate, etc.).

New Data:

Researchers, led by lead investigator Steven Narod, MD, from the Women’s College Hospital in Toronto, identified 108,000 cases of DCIS diagnosed from 1988 to 2011 in the Epidemiology, and End Results (SEER) database. They then compared the risk of dying from breast cancer in women with DCIS and in women in the general population, and estimated the hazard ratio for death from DCIS using a variety of factors, including age and treatment.

Many of the results confirmed previous studies, however, there were several surprising findings. First, one of the surprising findings was the overall risk of dying from breast cancer at 20 years post diagnosis (3.3%) in the study group did not differ from the chance that the average woman will die of breast cancer given by the American Cancer Society. Hence, treatment did not show any benefit in the study population overall.

One of the findings confirmed in the new study was that the mortality rate with DCIS was higher in women younger than 35 years at diagnosis, black women, and tumor markers linked to more aggressive cancer. However, since about 20% of the women diagnosed with DCIS had one or more of these characteristics associated with a higher risk for breast cancer death, and based upon the overall results of the study the researchers concluded that 80% of the women with DICS are better served with less aggressive therapy.

One of the other surprising study results was that prevention of recurrence of DCIS in the affected breast with radiation did not prevent death from breast cancer. The dominant thought has been that if you prevent DCIS from recurring it will, in turn, reduce the risk for breast cancer death, but that is not what the study found. In patients who underwent lumpectomy, the addition of radiotherapy was associated with a 50% reduction in the risk for DCIS recurrence at 10 years, but had zero effect in reducing breast-cancer-specific mortality at 10 years. The takeaway conclusion is that radiation therapy should not be routinely added to lumpectomy in women who are not at high risk, because it is associated with some risk for side effects and offer no benefit in reducing the risk for dying of breast cancer.

Similar results were found in the women in the study who underwent more aggressive surgery, like a mastectomy. The more aggressive treatment was good for reducing a recurrence, but not did reduce the risk for dying of breast cancer.

The results of this study calls into question whether all women with DCIS should be treated with aggressive therapy (surgery + radiation).

Commentary:

Instead of the term “watchful waiting,” I prefer “aggressive focus.” In other words, if you have DCIS (or prostate cancer or other non-invasive cancer), it is not about sitting around idle waiting for the worst possible outcome, it is all about aggressively focusing on the preventive, even reversal measures, through diet, lifestyle, and other natural approaches.

How will conventional medicine respond to the findings of this study (and others) that question the use of aggressive surgery and radiation for DCIS? No question it will be to start recommending estrogen antagonists like tamoxifen/raloxifene or aromatase inhibitors. In my opinion the use of these drugs in breast cancer treatment or prevention including women with prior history of breast cancer is the wrong way to go (see my book, How to Prevent and Treat Cancer with Natural Medicine for more information). I don’t like these drugs at all, especially when there are dietary and supplement strategies that I feel are much more rational.

Medical science is in a little bit of a limbo in that there is more and more evidence that conventional approaches are not delivering the desired outcome, but the data and sophistication of understanding how to use food as medicine is not quite where it needs to be to get more doctors to jump on that bandwagon. I fear what will happen here is that they will use drugs instead of diet simply because there is some data to support their use. Patients feel that they are stuck in the middle of choosing to follow their doctor’s recommendation or simply take charge of their health on their own. Often they try a combination of conventional medicine along with diet or alternative therapies.

As it relates to this particular situation about DCIS, the picture is getting more and more clear. Here is what I recommend: Opt for lumpectomy without radiation unless you are black or have aggressive tumor markers in which case, I would recommend lumpectomy with radiation. If you are under 40 with a diagnosis of breast cancer including DCIS, I would recommend seeing a naturopathic physician for aggressive natural support. In all cases, please see my recommendations on Breast Cancer Prevention.

On another note, in talking to women (including my wife) about mammography, they always seem to bring up someone who they know that had their life “saved” because a mammogram discovered a breast cancer early on and that allowed them to go down the treatment path. Is that story true? According to the data, it is a rare occurrence if it happens at all. There are basically three types of cancers found by mammography:

  • Very slow growing cancers where early detection offers no benefit to survivability.
  • Fast growing, aggressive cancers where even early detection by mammography is too late and the woman will die from the cancer anyway.
  • Cancers detected by screening mammography and whose treatment outcome may be better as a result of earlier detection.

According to various review articles, to find that 1 woman to possibly benefit from early detection it would require 1,000 healthy women screened every year for 10 years. It is simply not an effective tool. And what this new study illustrates, is that even if you find that 1 woman, unless she falls into the known higher risk categories, aggressive treatment may not be the best course of action.

Here is the takeaway message. Make breast cancer prevention the major focus and if you have a family or personal history of breast cancer, be even more aggressive in your breast cancer prevention plan. Again, for more information, see my recommendations on Breast Cancer Prevention.

Reference:

Narod SA, Iqbal J, Giannakeas V, Sopik V, Sun P. Breast Cancer Mortality After a Diagnosis of Ductal Carcinoma In Situ. JAMA Oncol. 2015 Aug 20. doi: 10.1001/jamaoncol.2015.2510.

August 25th, 2015

The Importance of Being “Awe Inspired”

awe inspiring

Introduction:

The field of positive psychology is providing valuable insights on exactly how our emotions influence our physiology. One are of body function that is very closely tied to our emotional experiences is the functioning of our immune system. Our emotional state not only influences how well we are protected from infection, but also the degree of inflammation that we may suffer from. Two new studies have found that the most powerful emotion in fighting inflammation is the feeling of awe.

Background Data:

While there have been a lot of studies on the impact of emotions on physical health, in general, these emotions are most often all lumped together. Negative emotions like grief, sadness, shame, fear, and anger are all viewed as having pretty much the same effects. The same is true for all positive emotions grouped into the general category of optimism or positive mood. What needs to be answered is if all positive emotions are created equal, or is there a way to boost certain body functions by focusing on experiencing more of a particular positive emotion.

New Data:

In an effort to better understand the different effects of various positive emotions, researchers conducted two studies at the University of California-Berkeley. The first study featured 94 freshman undergraduates who completed a questionnaire and provided a sample of the fluid from their inner cheek (oral mucosal transudate [OMT]). In the second study, 119 freshmen completed a questionnaire on their home computers using a secure website and then went to the lab for a follow up session where OMT was collected and another questionnaire was given.

In both studies interleukin-6 (IL-6) was measured from OMT samples. IL-6 is an important marker for inflammation that is influenced by the immune system. Higher IL-6 levels are associated with greater inflammation. In the first study, a questionnaire known as the Positive and Negative Affect Schedule (PANAS) was used to determine emotional status. In the second study, two additional questionnaires were used, the Dispositional Positive Emotion Scale (DPES) and The Big Five Personality Inventory were added as outcomes measures in addition to PANAS.

In both studies, positive emotions were associated with lower IL-6. In the second study, researchers were able to dig deeper into the type of positive emotion that had the most significant impact on IL-6 levels by examining the seven subscales of the DPES (awe, amusement, compassion, contentment, joy, love, and pride). Surprisingly, they found that awe had the strongest correlation to lower levels of IL-6 compared to any of the other emotions. In fact, only the degree of awe was able to significantly predict levels of IL-6. On the day the OMT was taken in the second study, the participants who reported feeling the most awe, wonder and amazement, that day had the lowest levels of IL-6. Joy, contentment, pride and awe were all strongly correlated with lower levels of IL-6; however, awe was the strongest predictor of low IL-6 levels.

The takeaway message from these studies is that it stresses the importance of fostering feelings of awe in our lives to positively influence the immune system and reduce inflammation.

Commentary:

O.K., let me answer the question “How do I experience more awe in my life?” Well, first of all, awe is often linked to feelings of social connectedness and social exploration. So from a practical perspective, the first step is to become more socially engaged. This goal is especially important if you are older of dealing with depression, because these situations often lead to social isolation. Here are some recommendations to become more socially engaged:

  • Get connected online. Using email, the Internet, and Web-based social networks such as Facebook or Twitter can make a big difference in helping people feel more connected.
  • Encourage positive relationships. A person is never too old to learn how to be a better friend, parent, mentor, or better listener. Personal development is a never-ending process.
  • Join a club or church. In today’s world, there are always opportunities to find places to socialize that are positive and healthful.
  • There is perhaps no greater opportunity to feel connected than by finding a way to volunteer time and energy towards a greater good. It is perhaps the most powerful way of connecting to people outside of our deepest personal relationships.

The health benefits of increased socialization are significant. Many of these benefits may be related to fighting inflammation and studies indicate that people who feel connected and have strong social relationships have lower levels of inflammatory markers in their blood.

Next, I would ask the question “What inspires you and causes you to feel awe?” What research shows is that something as simple as listening to music, walking in nature, or being creative, can have a positive impact on health. These effects may be related to feelings of awe.

For me, the things that really make me say “wow” are research studies like this one above. I am constantly reading studies that create an awe-inspired appreciation of the wonder of nature or the way in which our body and mind function. Of course, just looking around at nature or the stars is pretty awe inspiring to me. My message to you is to find a something that you can enjoy on a daily basis that makes you feel awe. It is important!

Reference:

Stellar JE, John-Henderson N, Anderson CL, et al. Positive affect and markers of inflammation: Discrete positive emotions predict lower levels of inflammatory cytokines. Emotion. 2015;15(2):129-133.

Dr. Michael Murray
8/25/15

August 18th, 2015

Flaxseed Consumption Lowers Cholesterol Levels

flaxseed

Introduction:

One of the most healthful additions to a heart healthy diet is ground flaxseeds. This wondrous little seed has played an important part of human history for over 5,000 years. Native to the Mediterranean, flax has been used not only as a food, but also for its fibers, which can be woven into linen cloth. Now most valued for its ability to reduce the risk of breast and prostate cancer, a new study from the Canadian Center for Agri-Food Research highlights another important effect in promoting cardiovascular health.

Background Data:

The major health benefit of flaxseeds has focused on their rich content of oil and the fiber components known as lignans. Flaxseed oil contains nearly twice the level of omega-3 fatty acids as fish oils – although it is the smaller-chain alpha-linolenic acid rather than the longer-chain fats like EPA and DHA found in fish oils.

Flaxseeds are the most abundant source of lignans. These components are fiber compounds that can bind to estrogen receptors and interfere with the cancer-promoting effects of estrogen on breast and prostate tissue. Lignans also increase the production of a compound known as sex hormone binding globulin, or SHBG. This protein regulates estrogen levels by helping to escort excess estrogen from the body. Ground flaxseeds as well as purified lignan dietary supplements (300 mg per day) have also been shown to lower blood LDL cholesterol levels. Ground flaxseeds consumption can lower blood pressure. In a double-blind study conducted at the St. Boniface Hospital Research Centre in Winnipeg, Canada, 30 g of ground flaxseed consumed daily produced an average reduction of 15 mm Hg in systolic blood pressure and 7 mm Hg in diastolic blood pressure in hypertensive patients.

New Data:

The purpose of the study was to evaluate the effects of dietary flaxseed on plasma cholesterol in a patient population with clinically significant peripheral artery disease (PAD) including many who were taking statins to lower LDL cholesterol levels. Patients (110) consumed daily foods that contained either 30 g of milled flaxseed or 30 g of whole wheat for one year. Plasma lipids were measured at 0, 1, 6, and 12 months.

Dietary flaxseed in these PAD patients resulted in a 15% reduction in circulating LDL cholesterol as early as 1 month into the trial. Results at one year, however, did not reach statistical significance in all patients. Interestingly, in the subgroup of patients taking flaxseed and statins (n = 36), LDL-cholesterol concentrations were lowered by 8.5% compared with baseline after 12 months. This result indicates that flaxseed consumption provides additional LDL-cholesterol-lowering capabilities when used in conjunction with statins.

Commentary:

The takeaway message from the study is that a simple dietary addition can produce significant health benefits. Most of the beneficial research has focused on the use of ground flaxseeds, as this form allows for the beneficial compounds to be more easily liberated compared to consuming the whole seeds. When buying ground flaxseeds it is highly recommended to purchase ground flaxseeds in a vacuum-sealed package or has been refrigerated since once flaxseeds are ground; they are much more prone to oxidation and spoilage. Here are some quick serving ideas:

  • Sprinkle ground flaxseeds onto your hot or cold cereal.
  • Add ground flaxseeds to your breakfast shake.
  • Mix in with yogurt.
  • To give cooked vegetables a nuttier flavor, sprinkle some ground flaxseeds on top of them.

Reference:

Edel AL, Rodriguez-Leyva D, Maddaford TG, et al. Dietary flaxseed independently lowers circulating cholesterol and lowers it beyond the effects of cholesterol-lowering medications alone in patients with peripheral artery disease. J Nutr. 2015 Apr;145(4):749-57.

Dr. Michael Murray
8/18/15