Kathleen Wesa

The public health impact of herbs and nutritional supplements

Dietary supplement use has increased exponentially in recent years despite the lack of regulatory oversight and in the face of growing safety concerns. This article provides an overview of the public health implications and safety concerns associated with dietary supplement use, especially by cancer patients. Botanical research is actively pursued at the Memorial Sloan-Kettering Cancer Center (MSKCC) Integrative Medicine department. Work of the MSKCC Center for the Study of Botanical Immunomodulators is described, and guidelines for cancer patients’ use of dietary supplements outlined. Herbs and other botanicals are complex, physiologically active agents, but little is known about most of the popular, widely available dietary supplements. Herb–drug interactions, a major concern, are exacerbated in the cancer setting. Biologically active agents may interfere with chemotherapy and other prescription medications. They may exert anticoagulant activity at rather inconvenient times such as during surgery, and create other serious problems. Research on the bioavailability, effective dosage, safety, and benefits of these complex agents is sorely needed. Oncology professionals and other health care providers should educate themselves and their patients about these issues. Probably the largest, continuously updated free information resource is MSKCC’s AboutHerbs website (www.mskcc.org/AboutHerbs).

Integrative Oncology: Complementary Therapies for Cancer Survivors

Cancer survivors experience a wide range of symptoms during and following completion of treatment, and some of these symptoms may persist for years or even decades. While pharmacologic treatments relieve many symptoms, they too may produce difficult side effects. Complementary therapies are noninvasive, inexpensive, and useful in controlling symptoms and improving quality of life, and they may be accessed by patients themselves. Rigorous scientific research has produced evidence that acupuncture, massage therapy, music, and mind-body therapies effectively and safely reduce physical and emotional symptoms. These therapies provide a favorable risk-benefit ratio and permit cancer survivors to help manage their own care.

Serum 25-hydroxy vitamin D and survival in advanced colorectal cancer: a retrospective analysis.

Higher serum 25-hydroxy vitamin D [25(OH)D] levels are associated with decreased colorectal cancer (CRC) incidence. In this retrospective study of Stage IV CRC patients, we evaluate whether 25(OH)D levels at diagnosis correlate with survival. Stored sera from carcinoembryonic antigen (CEA) measurements obtained between February 2005 and March 2006 were screened. The first 250 patients with CEA ±30 days of Stage IV CRC diagnosis were included. Serum 25(OH)D levels were determined and categorized as adequate ≥30 ng/mL, or deficient <30 ng/mL. Multivariable Cox regression models controlling for albumin and Eastern Cooperative Oncology Group performance status were used to investigate whether higher 25(OH)D levels were associated with prolonged survival. A total of 207 patients (83%) were vitamin D-deficient (median = 21 ng/mL), with deficiencies significantly more likely among non-Hispanic black patients (P = 0.009). Higher levels were associated with prolonged survival in categorical variable analysis: adequate vs. deficient, hazard ratio = 0.61, 95% confidence interval = 0.38–0.98, P = 0.041. A majority of newly diagnosed Stage IV CRC patients are vitamin D-deficient. Our data suggest that higher 25(OH)D levels are associated with better overall survival. Clinical trials to determine whether aggressive vitamin D repletion would improve outcomes for vitamin D-deficient CRC patients are warranted.

Is there a role for complementary therapy in the management of leukemia

Patients with leukemia often seek additional treatments not prescribed by their oncologist in an effort to improve their cancer treatment outcome or to manage symptoms. Complementary therapies are used in conjunction with traditional cancer treatments to decrease symptoms and side effects associated with cancer or cancer treatment, and to improve patients’ overall quality of life. Complementary therapies are distinct from so-called ‘alternative’ therapies, which are unproven, ineffective and may postpone or interfere with mainstream cancer treatment. Complementary therapies are pleasant, inexpensive, nonpharmacologic and effective. For patients with leukemia, the complementary therapies that are always appropriate include mind–body interventions, such as self-hypnosis, meditation, guided imagery and breath awareness. Massage and reflexology (foot massage) decrease symptoms with effects lasting at least 2 days following treatment. Acupuncture is very beneficial for symptom management without adverse consequences. Physical fitness with regular exercise and healthy dietary habits can significantly decrease side effects of cancer treatments and may prolong survival. Botanical extracts and vitamin supplements may interfere with active cancer treatments, and should be discussed with the oncologist or pharmacist before use.

Serum 25-hydroxyvitamin D testing at Memorial Sloan-Kettering Cancer Center.

9121 Background: Vitamin D (D) is a fat soluble vitamin/hormone involved in calcium homeostasis. In vitro, animal model and clinical studies show that D affects immunomodulation, apoptosis and cellular differentiation in addition to skeletal effects. D is obtained primarily through UV exposure (sunlight) or through fortified foods (milk). A recent IOM report stated most people have sufficient vitamin D levels and that supplementation is not necessary. D testing and results of serum D levels at MSKCC were evaluated to characterize the D status of MSKCC patients. METHODS A search was performed for MSKCC patients with for whom serum vitamin D 25-hydroxy levels evaluated were taken from January 1, 2003 to June 31, 2010. Demographic information including age, race, BMI and survival status also were obtained. RESULTS There were 23,909 serum 25-hydroxy vitamin D tests ordered from January 1, 2003 through June 30, 2010 for 12,817 unique individuals. The largest volume of tests (57%) was performed in breast cancer patients. The next largest volume was for colorectal cancer patients (9%), followed by leukemia (7%) and lymphoma (7%). Only 311 (1.3%) of the patients with endometrial cancer had D levels obtained. 75.8% of patients were deficient in vitamin D as defined by serum levels <30 ng/ml. The median vitamin D level was 24.6 ng/ml. In 2003 there were 396 D tests ordered; 846 D tests in 2006; 1711 D tests in 2007; 3928 D tests in 2008 and 8133 D tests in 2009. The majority of patients (53%) did not have serial D testing. CONCLUSIONS The vast majority of patients who had their serum vitamin D level monitored were deficient. An exponential increase in the volume of vitamin D tests ordered over the past 3 years was seen. Most patients are D deficient (defined by serum 25-hydroxy D < 30 ng/ml). A recent IOM consensus statement described most people as sufficient in D, however our study does not support this conclusion. Whether treating D deficiency would improve patient outcome remains to be determined. D status should be considered for all patients deficiency corrected. Clinical trials evaluating D repletion and survival are warranted.