Appendix C: Herbal Supplements

Question 1

Aloe

Answer 1

May be used for constipation as aloe juice and aloe vera gel

Can help with radiation dermatitis in patients with H&N cancer

Radiation proctilitis improved in those who used aloe vera

Question 2

a-Lipoic acid

Answer 2

Food sources: Broccoli and Spinach

cellular antioxidant that is important for energy production

Helps improve insulin sensitivity and diabetes management

May reduce symptoms of neurotoxicity with oxaliplatin and cisplatin

Inhibits growth of breast, colon, lung, liver and pancreatic CA cells

Used orally or given IV to help improve fasting glucose in patients with T2DM

Question 3

black cohosh

Answer 3

Suppresses symptoms of hot flashes associated with menopause and CA treatments (hormonal)

Possibly not safe with pregnancy or lactation

Can interfere with Tamoxifen and increase toxice effects of doxorubicin and docetaxel

Question 4

coenzyme Q10

Answer 4

Fat soluble substance found in every cell of the body

Endogenous antioxidant involved in cellular energy production

Low plasma levels are associated with increased risk of breast CA and melanoma

May reduce:
- renal and cardiotoxicity associated with Doxorubicin.
- radiation induced nephropathy
- renal toxicity associated with doxorubicin and carboplatin

Contraindicated if taking Warfarin

Question 5

curcumin

Answer 5

Safe

naturally occurring polyphenol found in the Tumeric plant

Anti- inflammatory, antioxidant, anticancer properties, may inhibit growth of cancer cells

Shown to have therapeutic effects in: lung, cervical, prostat, breast, osteosarcoma, liver, esophagea, and gastric cancers

May enhance anticancer effect of 5FU, and combo of 5FU and Cisplatin

Improves myelosuppression induced by carboplatin

Reverses resistance to irinotecan in colon cancer cells

may increase efficacy of cisplatin to tumors cells that were cisplatin resistant and reduces neurotoxicity

Works better when combined with black pepper

Question 6

3,3-Diindolylmethane (DIM) and indole-3-carbinol (I3C)

Answer 6

bioactive metabolite found in cruciferous vegetables

DIM and I3C affect multiple signalling pathways and target molecules controling cell division apotosis and angiogenesis

May interfer with hormonal therapy d/t potential antiestrogenic effects

Reduced doxorubicin induced oxidative stress in cardiac tissues by reducing leves of free radicles and lipid peroxidation

enhanses therapeutic efficacy of paclitaxel in gatstric cancer

Question 7

flaxseed

Answer 7

excellent source of alpha linolenic acid and rich in lignands

source of soluble and insoluble fiber

phytoestrogenic and antioxidant properties

Increases markers of apoptosis and decreases cancer cell proliferation

may inhibit growth of breast and prostate cancer

Consuming 25 grams of flaxseed daily may reduce cancer growth in wemone with breast cancer

must be ground to show biologic effects

1-2 Tbsp/day safe

may cause possible: nausea, gas, diarrhea

Question 8

garlic

Answer 8

may stimulate apoptosis and help regulate cell cycles

a study looking at the effect of garlic extract found that cell proliferation was reduced by 80% in all cell types (breast, prostate, colon)

garlic is associated with lower risk of gastric cancer

Question 9

ginger

Answer 9

may help nausea, heartburn, anorexia, diarrhea and gas

has antioxidant and anti-inflammatory properties

may inhibit angiogenesis

Ginger juice and acetone extract of ginger reversed delayed gastric emptying 2/2 to cisplatin therapy

Mixed evidence on effect of ginger on N/V

Question 10

ginkgo biloba

Answer 10

may inhibit proliferation of cancer cells

may reduce toxicity of cisplatin

may help enhance tumor reduction with tamoxifen

May inhibit activity with anticoagulants and anti-seizure medicines

Question 11

glutamine

Answer 11

most abundant non-essential amino acid in the body
- involved in cell cycle replication for rapid cell turnover in the GI mucosa and immune system
- may reduced inflammatory side effects of cancer treatment (mucositis, stomatitis, esophagitis, diarrhea)
- helps maintain mucosal barrier
-15 grams 2x/day for 7 days following oxaliplatin reduces peripheral neuropathy and severity
- evidence not as great for use in auto HCT
- contraindicated with antiseizure medication and lactulose

Question 12

green tea

Answer 12

• antiobesity, anticancer, anti bacterial antiviral, hepatoprotective, cardoprotective, and neuroprotective benerfits
• demonstrated to inhibit tumorigienesis in animal modals

variety of drug interactions d/t inhibitory effects of Cytochrome P-450 izozymes

**should not be taken with Tarceva (erlotinib) and Votrient (pazopanib) and Velcade

Question 13

melatonin

Answer 13

-sleep aid
-may increase effects of herbs with anitcoagulant products, so in theory could increase risk of bleeding
-possibly help with some chemos: increase effect of Oxaliplatin, cisplatin, 5-FU, gemcitabine, tamoxifen
-might help/limit development neuropathic pain

generally safe and well tolerated — 1-5 mg/d for insomnia and up to 20 mg/d for anticancer effects

Question 14

N-acetylcysteiene (NAC)

Answer 14

Antioxidant that contains thiol groups–stimulates glutathione synthesis and scavengers free radicals

-can improve chemo by enhancing cytotoxic effects of the chemo and protecting the host tissues—cisplatin, 5-FU, cyclophosphamide, ifosfamide, methotrexate, oxaliplatin, doxorubicin, combined carbo, melphanin, and etoposide phosphate

generally safe and well tolerated with minimal side effects
600-1800 mg/day.

Question 15

Omega-3s — EPA and DHA

Answer 15

cardioprotective, anti-inflammatory and immunomodulatory effects, may reduce inflammation

Might help with breast cancer and endometrial cancer risk.
Might help with neuropathy with paclitaxel.
Might enhance doxorubicin, cisplatin, vincristine (omega 3) and combo of oxaliplatin and 5-FU (EPA)

Omega-3 from food is best. EPA/DHA up to 3 g/day is considered safe. no more than 4 g/day but need MD monitoring for bleeding risk

Question 16

Quercetin

Answer 16

Flavonoid in foods and tea, also supplement

anti-inflammatory, induces apoptosis in breast cancer cells
more studies are needed for safety and tolerability when used IV—side effects of flushing, sweating, N/V and dyspnea reported

can bind with iron and therefore decrease bioavailability - possibly increasing iron deficiency in vulnerable individuals undergoing treatments. though it might be beneficial for patients at risk of hemochromatosis

oral is safe and well tolerated in foods (citrus, apples, onions, parsley, tea)

Question 17

Reishi mushroom

Answer 17

bioactive compounds, such as polysccharides, triterpenoids, alkaloids, enzymes and protein.

Used to prevent aging, enhance the immune system, and treatment for HTN, high lipids, viral infections like flu, cancer, inflammatory disease, CVD, DM, asthma and bronchial diseases

possibly unsafe when used in powdered form for more than 1 month
may increase risk of bleeding when combined in high doses (>3 g/day) with anticoagulant meds

one small study found 1000 mg powder, 3-4 times/day for 4 weeks, helped with cancer related fatigue in breast cancer patients on endocrine therapy

no evidence to support front line treatment but could be used to enhance tumor response and host immunity – in caution.

most studied mushroom with respect to hepatoprotective effects

Question 18

resveratrol

Answer 18

phytoestrogen, antioxidative, anti-inflammatory, antimutagenic

has antiplatelet effects, so could cause excessive bleeding in persons on blood thinners

found possibly effective in many cancers
can reduce cisplatin renal toxicity
possible radiosensitizer of breast cancer cells
might help prevent bone loss with methotrexate (1 mg/kg body weight)

root of knotweed (polygunum) is a rich sources. Grapes (black more than red or green)–grape skins

Question 19

selenium

Answer 19

cofactor for glutathione peroxidase, an enzyme of antioxidant defense system

excessive amounts can cause acute toxicity – N/V, abd pain, dermatitis, nail changes, fatigue, irritability, alopecia, impaired endocrine function, neurotoxicity and wt loss

Most research suggests selenium does NOT reduce risk of cancer
Might enhance effects of cisplatin on breast cancer
may help with taxol and etoposide
might help with docetaxel in breast
might mitigate potential for 5-FU induced mucositis

Orally selenium is safe and well tolerated in dosages up to Tolerable Upper Intake Level of 400 mcg/d

Question 20

silymarin (milk thistle)

Answer 20

antioxidant, immunomodulatory effects, anti-inflammatory effects, liver-protective, anti-cancer

allergic reactions reported in >1,500 mg/d
CAUTION with tamoxifen
might reduce side effects of cisplatin (rat study) – not found to help with AKIs in cisplatin
might reduce severity of radiotherapy-induced mucositis and delay occurrence in ENT pts

Generally well tolerated
Better taken as Silybin-PC to improve bioavailability

Question 21

St. john’s Wort

Answer 21

Herbal–yellow flower

may interact with many medications, including warfarin

possibly make colorectal cancer cells more responsive to treatment
not enough strong evidence to recommend for cancer treatments, particularly due to interactions with other meds

AVOID for all concurrent chemotherapy due to possible effects on enzyme inductions for multiple enzymes

Question 22

Theanine

Answer 22

amino acid found in tea and mushrooms - antioxidant

may enhance efficiency of doxorubicin and idarubicin and reduce their side effects

few side effects, but might lower BP (interact with HTN meds)

no evidence that taking supplements is more effective than drinking it in tea – common dosage is 200 to 400 mg daily or BID, max 1,200 mg

Question 23

Turkey tail mushrooms

Answer 23

antimicrobial, antiviral, immunomodulatory, antitumor — big in Ancient Chinese Formulations/medicine

low incidence of mild/tolerable side effects

found might help with survival for cancer, particularly breast, gastric, and colorectal, and lung.
might help reduce radiation side effects

safe/well tolerated
dosage is 3 g of extract/day

Question 24

vitamin D

Answer 24

regulate genes that influence cell proliferation/apoptosis

toxicity–can result in hypercalcemia

studies back/forth on low Vit D and increased cancer risk and vise versa

Important for overall health, including cancer prevention
bioavailability of D3 (cholecalciferol) is greater than D2 (ergocalciferol)
Upper level revised to 4000 IU/d
Endocrine Society recommends maintaining 25-hydroxyvitamin D blood level of 40-60 ng/mL is ideal, up to 100 mg/mL is safe