A Case Study
Laura A. James, ND
Even before I opened my satellite practice in naturopathic oncology in Bellingham, WA, I got a call from a 37-year-old female, Mrs. R, who was diagnosed in November 2006 with breast cancer. She had been about to start chemotherapy for Stage III, ER/PR+, Her 2 neu – intraductal carcinoma when she found out that she was pregnant.
This otherwise healthy, non-smoking, stay-at-home mother of two had a primary complaint of left arm pain. A breast lump was felt on exam by her primary care physician, another naturopathic physician. She had palpable left axillary lumps as well, but she had no other symptoms except fatigue. She was sent for mammogram, then ultrasound and biopsy. Positive for breast cancer, she was referred to oncology and surgery. Her breast lump was 1.8×1.0x0.8 cm on ultrasound, and the largest, deepest axillary lump was 2.6×2.2×2.0 cm. Follow-up studies included chest, abdomen, and pelvic CT-scans that revealed left breast and axillary involvement, left supraclavicular adenopathy, possible mediastinal adenopathy, multiple pleural-based nodules, and a sclerotic area of cervical bone. A bone scan showed increased uptake in the lower cervical spine that had not been identified on plain films. Routine labs in preparation for a PET-scan and port placement revealed an elevated beta hCG. Surprisingly, she was four weeks pregnant at diagnosis, and Mrs. R was strongly encouraged to terminate the pregnancy so that she could proceed with cancer treatment.
But Mrs. R was a deeply spiritual woman, very involved in her church, and very dedicated to her two young daughters. She would not terminate. She was also very confident that if she collected the right team of providers—MDs, NDs, energy healers, and spiritual counselors—that both she and her baby would be okay. I told her up front, “I have absolutely no experience with cancer and pregnancy, but I will do my best.” To which she replied, “That’s okay, I want you on my team,” a team that included a Seattle oncologist, a Bellingham oncologist, a University of Washington Ob/Gyn and myself.
Only 3.8% of pregnancies are complicated by breast cancer and 10% of women under 40 diagnosed with breast cancer are pregnant.1 As more women delay becoming pregnant, oncologists expect these numbers to increase. Physicians usually recommend termination of these pregnancies, as chemotherapy and radiation can have significant teratogenic effects if given in the first and early second trimester. Not all women can bring themselves to terminate, however, and many of these women seek out care at MD Anderson (MDA) in Texas where they have pioneered a protocol of FAC [5-FU, adriamycin (doxorubicin hydrochloride) and cytoxan] after week 15 for treating pregnant women with breast cancer and successfully delivering their babies. At MD Anderson, 70% (38 of 54) of women treated for breast cancer while pregnant are alive and disease free after FAC therapy. Most of the babies were born at or near term, and only two presented with congenital abnormalities.2 New data from MDA state that women with pregnancy-associated breast cancer do not have higher rates of local recurrence, distant metastases, or diminution of overall survival compared with other young women with the disease. They are, however, more likely to be diagnosed later, with very aggressive disease, and have treatment delayed.3
Mrs. R’s conventional treatment was withheld until after the first trimester was complete. Additionally, to minimize radiation of the developing fetus, all scans (MRI, PET) that could have been used to stage her disease were avoided. Initially, she was Stage IIIC (tumor extension to chest wall, skin, and lymph nodes above/below the collarbone and around sternum), but there was a strong suspicion that her cancer had metastasized. Surgery would be scheduled for the third trimester, then after delivery, Mrs. R would receive paclitaxel, radiation, and hormone modulation.
I saw Mrs. R in my office in Bellingham in January 2007. Physical exam revealed a hard, mobile, approximately 1cm lesion at 1 o’clock on her left breast, with some skin dimpling above and below the lesion. There was significant lymphadenopathy of the left axillary nodes and swelling at the biopsy site. Her symptoms included nausea, fatigue, and constipation. Early labs were normal except for a vitamin D 25-OH of 50.1 ng/dL and NK cell function of 6. She was 8.5 weeks pregnant. History included first pregnancy after age 30, and breast cancer in a distant female relative.
Since I am not trained as a midwife, I solicited advice from an ND/LM colleague regarding teratogenicity of herbs and nutrients. Our antepartum list was as follows:
- Fish oil 3 g to decrease inflammation, increase cell membrane stability, and enhance nervous system function especially of fetus
- Vitamin D 2000 IU to correct deficiency
- Green tea 3-4 cups daily (decaf) for EGCG’s myriad anti-cancer benefits
- Coriolus versicolor mushroom 3 g and Maitake D Fraction 120 mg to stimulate NK cell function
- Lactobacillus acidophilus 75 billion organisms for constipation
- Calcium-D-Glucarate 500 mg to modulate estrogen metabolism
- Whey protein smoothies daily for inflammation modulation and to deliver nutrients when unable to take pills
- Flax seed 1 Tbsp for lignin benefit and to encourage bowel regularity
- Whole foods diet plan
The hospital’s pharmacist used Natural Medicines Comprehensive Database to research my protocol. I had to laugh, however, when her recommendations came back that fish oil was suspect for use during pregnancy. And here they were planning to give this patient cytotoxic drugs!
Five cycles of neoadjuvant chemo (adriamycin and cytoxan) began for Mrs. R in February 2007; she was 15 weeks pregnant. Additional medications included lorazepam, ondansetron hydrochloride, and omeprazole, along with potassium to mitigate side effects. She experienced significant but manageable nausea and constipation, and complete alopecia toxica. She became anemic and pancytopenic, and was generally fatigued; she received granulocyte colony-stimulating factor The patient’s conventional doctors prescribed letrozole (aromatase inhibitor), leuprolide acetate (GnRH agonist), and zoledronic acid (bisphosphonate) for ongoing treatment. PET-CT in October 2008 revealed stable metastatic disease. Side effects have included chemically-induced menopause with associated symptoms, and weight gain. She remains fatigued, but generally well. She continues carnitine, EGCG, DIM, Coriolus versicolor, fish oil, and a multivitamin. We
added:
- Gamma oryzanol 300 mg tid for hot flashes
- Adrenal support
- Dietary and exercise recommendations
In March 2009, Mrs. R is a post-menopausal cancer survivor with three beautiful, healthy, active girls. Baby Jazmine, the “miracle” baby, is the feisty one. I think she gets that from her mother. (G-CSF). Her blood sugar was elevated at 165 mg/dL, and a glucose tolerance test (GTT) was ordered. A sixth cycle was withheld because of suspicion of fetal anemia. Amazingly, her spirits remained high.
By June 2007, things moved quickly. Mrs. R declined any further chemotherapy. She had surgery to remove the breast tumor and affected lymph nodes on 6/18/07, an MRI on 6/19/07 that detected bone metastases, and on 6/20/07 Baby Jazmine was born! She was delivered at 37 weeks, and was 17” long, 3 lbs 8 oz, and perfectly HEALTHY!
Radiation commenced in July 2007. Mrs. R received a five-day course to her spine for metastases. She then completed a two-month course to her breast in Bellingham. It was hard to tell if her fatigue stemmed from her newborn or the radiation, but Mrs. R remained feeling generally well, although she continued to be pancytopenic. Post-partum, we added the following to her existing protocol:
- Acetyl-L-carnitine 1 g for fatigue
- CoQ10 100 mg for heart muscle postdoxorubicin hydrochloride treatment
- Di-indolemethane (DIM) 150 mg tid to alter estrogen metabolism to beneficial 2-OH estrone
- Melatonin 40 mg hs to modulate cytokines
- Pancreatic enzymes for digestion and anti-cancer effect
- Curcumin 500 mg tid to radiosensitize cells to radiation
- EGCG 500 mg tid for myriad anticancer effects
- Astragalus 300 mg bid to bolster immunity
- Arabinogalactan 500 mg bid to increase NK cell function
- A Chinese herbal formula for red cell stimulation
The patient’s conventional doctors prescribed letrozole (aromatase inhibitor), leuprolide acetate (GnRH agonist), and zoledronic acid (bisphosphonate) for ongoing treatment. PET-CT in October 2008 revealed stable metastatic disease. Side effects have included chemically-induced menopause with associated symptoms, and weight gain. She remains fatigued, but generally well. She continues carnitine, EGCG, DIM, Coriolus versicolor, fish oil, and a multivitamin. We added:
- Gamma oryzanol 300 mg tid for hot flashes
- Adrenal support
- Dietary and exercise recommendations
In March 2009, Mrs. R is a post-menopausal cancer survivor with three beautiful, healthy, active girls. Baby Jazmine, the “miracle” baby, is the feisty one. I think she gets that from her mother.
Laura A. James, ND is a graduate of Tufts University, as well as Bastyr University’s naturopathic medicine program. She practices complementary care for cancer patients in both Bellevue and Bellingham, Wash. She counsels patients on whole foods nutrition, botanical medicine, nutritional supplements and lifestyle modifications to attain optimum mind/body balance as they go through cancer treatment and into survivorship. Dr. James is trained in safely managing CAM therapies with conventional medicine and is a member of the Oncology Association of Naturopathic Physicians. She is also trained in biofeedback modalities for stress management and chronic symptom control.
References
1. MD Anderson Web site. www.mdanderson.org.
2. Hahn KM et al. Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero. Cancer. 2006;107(6):1219-1226.
3. Beadle BM et al. The impact of pregnancy on breast cancer outcomes in women<or=35 years. Cancer. 2009;115(6):1174-1784.
