Hope: Is there relief for breast cancer patients?
Hope: Is there relief for breast cancer patients?
Black cohosh, exercise may help
Now it seems that there are more safe options than ever for addressing hot flashes and other symptoms of menopause in breast cancer patients, and at the same time, there are some new warnings as well. Recent research from Columbia University in New York City shows that black cohosh may safely provide nonhormone-based relief for hot flashes and appears to be acceptable for at least two months in women suffering from tamoxifen-enhanced sweating.1 A Mayo clinic study additionally recommends vitamin E to help relieve hot flashes.2
And another study from Duke University in Durham, NC, shows that exercise prevents chemotherapy patients from accumulating extra body fat while improving quality of life.3 And finally, the warning: The jury is still out on the safety of soy foods for breast cancer survivors.
Relief for menopausal symptoms
Many perimenopausal and menopausal women taking tamoxifen report intense, sometimes almost unbearable, hot flashes and sweating. Black cohosh traditionally has been used to relieve menstrual and menopausal discomfort. Judith Jacobson, DrPh, MBA, assistant professor of clinical public health at Columbia University, found that taking black cohosh for two months had no effect on the level of hormones that may increase risk of recurrence. The black cohosh group reported a 27% reduction in the number of hot flashes, but a significant reduction in the amount of sweating.
"Some women may differentiate sweating from hot flashes. This is a matter of whether the cup is half full or half empty," says Jacobson. "The improvement was there, and we have shown it causes no harm in terms of hormonal increases, at least in the 60-day period our subjects used it."
One of the 85 women with breast cancer who participated in Jacobson’s double-blinded study told the researcher she was extremely excited about the wonderful relief she was getting from the pills she had been given. Jacobson recalls, "I said to her, What if we find out you are on the placebo?’ and she said she didn’t care as long as it was working. In fact, at the end of the trial, we found she was on the placebo."
"Quality of life is extremely important to breast cancer survivors. I really don’t care what’s in the black box, if it works and it doesn’t hurt people, I’m for it," she adds.
The German Commission E reported estrogen-like action, luteinizing hormone suppression and binding to estrogen receptors with black cohosh use. However, no estrogen-like effects have been noted with Remifemin (distributed by GlaxoSmithKline in the United States), the most widely used black cohosh extract, so it has been widely recommended as a remedy acceptable for breast cancer survivors.
Placebo-controlled and open clinical monitoring trials with black cohosh in healthy women, and worldwide use for more than 40 years, have a shown a 70% reduction in hot flashes and other symptoms in the majority of women over 12 weeks. Based on the divergence between previous findings of the effectiveness of black cohosh in healthy women, Jacobson says further research is necessary.
One-third of the women in Jacobson’s study were not in the normal range for natural meno-pausal symptoms, and the majority was taking tamoxifen, which can produce menopausal symptoms. Many experts theorize that drug-induced and natural hot flashes differ in nature and severity. Follicle-stimulating hormone and luteinizing hormone were measured by blood tests at the beginning and end of the study.
Jacobson notes that her two-month study might have been too short to produce full results. Remifemin package labeling says relief may take up to 12 weeks. Jacobson also noted that placebo effects typically wear off with time and a longer study might have picked up a difference between the active and placebo groups.
"The important thing here is that this study confirms that Remifemin is a safe alternative for women who cannot or choose not to take estrogen. Black cohosh caused no changes in female reproductive hormone levels," says Susan Love, MD, adjunct professor of surgery at the University of California, Los Angeles.
The Mayo Clinic review of current literature on nonhormonal alternatives for the treatment of hot flashes in breast cancer survivors as well as in healthy women resulted in a determination that 800 IU of vitamin E daily is a "reasonable choice for women experiencing mild hot flashes." If the vitamin E was not effective, the Mayo review recommends antidepressants clonidine and vanlafaxine and finally progestations agents, such as megestrol acetate or intramuscular injections of depomedroxyproegesterone. The Mayo study did not recommend black cohosh or soy. The Mayo researchers also suggest nonpharmacological approaches, such as paced breathing, progressive muscle relaxation, avoiding alcohol and spicy foods, and wearing loosely woven cotton clothing.
Exercise for chemotherapy patients
Exercise and chemotherapy seem like impossible partners, but a Duke study shows that breast cancer patients who engaged in a moderate exercise program while they were undergoing chemotherapy reported improved quality of life during the difficult period of chemotherapy. In addition, they did not gain body fat, which might place them at higher risk for other diseases and possibly for a recurrence of breast cancer. Weight gain is common during chemotherapy for breast cancer, and many oncologists assumed the women were simply overeating.
The Duke study, funded by the National Cancer Institute, showed that women receiving chemotherapy gained 2.1 kg vs. a 1 kg gain among those who received only localized treatment — surgery with or without radiation. Researchers measured and compared diet, activity, resting metabolism, and body composition in 53 premenopausal, early-stage breast cancer patients over the course of one year.
"This study shows that these patients are not overeating; they are underactive," says Wendy Demark-Wahnefried, PhD, associate research professor of surgery at Duke in Durham, NC. "The data suggest that chemotherapy-induced weight gain is distinctive and indicative of sarcopenic obesity (weight gain in the presence of lean tissue loss or absence of lean tissue gain)," Demark-Wahnefried writes.
In the general population, weight is gained in both lean muscle tissue and fat," she says. "In premenopausal breast cancer patients receiving chemotherapy, however, we saw an increase in adipose tissue while lean tissue stayed the same or even decreased. So patients became fatter’ even if their weight stayed the same."
The body composition changes induced by chemotherapy "physiologically are comparable to a woman aging 10 years in one year," she says. "Exercise may be the only way to stop the loss of lean tissue mass, which seems to occur even if there is no weight gain." Her advice: Breast cancer patients receiving chemotherapy should be advised to exercise daily, first thing in the morning, emphasizing resistance training in the lower body to maintain lean tissue mass and prevent weight gain. Clinicians need to advise their patients to plan the exercise time and not wait until the end of the day when they are too tired.
"They should make exercise part of their lives. I know it’s hard, but the more they experience it, the more it becomes self-reinforcing," says Demark-Wahnefried. Patients who exercised reported they had more energy and less nausea. "It’s also something to take their minds off what they are going through," she adds.
Soy — good, bad, or indifferent?
Conflicting opinions are now emerging among soy researchers about the health benefits of the lowly bean once considered a miracle stopper of heart disease, shield against cancer, and a source of inexpensive nutrition. There is now concern that soy may be a source of estrogen and, as such, could promote primary breast cancer or the recurrence of the disease in survivors.
Numerous studies indicate the consumption of soy products may be heart- and chemo-protective, including a recent Vanderbilt University study of Chinese women that showed high soy intake early in life may reduce the risk of breast cancer in later life.4 And a 1997 Japanese study shows that consumption of soy products lowers the risk of developing breast cancer by modifying estrogen metabolism.5
While soybeans are high in protein and essential fatty acids, they are a rich source of isoflavones, which are plant-derived estrogens, chemically similar to, but weaker than, human estrogen. Because of the phytoestrogen content of soy products, some physicians caution women against eating too much soy for fear of promoting tumor growth, especially in women whose breast cancer is sensitive to estrogen.
Eating soy in moderation should not be problematic for women with breast cancer, says Wahida Karmally, MS, RD, director of nutrition at the Irving Center for Clinical Research at Columbia Presbyterian Medical Center, also in New York City. "If you occasionally have tofu with a meal, that’s fine. It’s when people drink lots of soy milk and take soy supplements [which contain concentrated isoflavones] — that could be a problem," says Karmally, who is a spokeswoman for the American Dietetic Association. "We don’t know if it is dangerous, but we should be conservative about it until we do know," she adds.
Much of the current debate over the health benefits of soy began two years ago when two Food and Drug Administration (FDA) scientists strongly opposed health claims on soy products (the FDA was considering allowing soy product manufacturers to include a health claims with their products). "We oppose the health claim because there is abundant evidence that some of the isoflavones found in soy demonstrate toxicity in estrogen-sensitive tissues and in the thyroid," wrote FDA senior toxicologists Daniel Sheehan, PhD, director of the FDA’s estrogen base program and Daniel Doerge, PhD, of the FDA’s division of biochemical toxicology. "Given that a woman’s own estrogens are a very significant risk factor for breast cancer, it is unreasonable to approve the health claim until complete safety studies of soy protein are conducted," they added.
The FDA leadership overrode Sheehan and Doerge’s concerns, saying the weight of evidence supports soy’s benefits. However, the FDA Consumer magazine carried a lengthy article in its May-June 2000 issue carrying Sheehan and Doerge’s warnings.
References
1. Jacobson JS, Troxel AB, Evans J, et al. Randomized trial of black cohosh for the treatment of hot flashes among women with a history of breast cancer. J Clin Oncol 2001; 19:2,739-2,745.
2. Loprinzi CL, Barton DL, Rhodes D. Management of hot flashes in breast cancer survivors. Lancet Oncology 2001; 2:199-204.
3. Demark-Wahnefried W, Peterson BL, Winer EP. Changes in eight, body composition and factors influencing energy balance among premenopausal breast cancer patients receiving adjuvant chemotherapy. J Clin Oncol 2001; 19:2,381-2,389.
4. Shu XO, Jin F, Dai Q, et al. Soyfood intake during adolescence and subsequent risk of breast cancer among Chinese women. Cancer Epidemiol Biomarkers Prev 2001; 10:483-488.
5. Nagata C, Kabuto M, Kurisu Y, et al. Decreased serum estradiol concentration associated with high dietary intake of soy products in premenopausal Japanese women. Nutr Cancer 1997; 29:228-233.
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