QUALITY OF LIFE (QOL) ISSUES IN CANCER Presented by: LARRY ALTSHULER, M.D. ST.THOMAS, V.I. Date: NOVEMBER 6, 2013.

QUALITY OF LIFE (QOL) ISSUES IN CANCER

Presented by: LARRY ALTSHULER, M.D.ST.THOMAS, V.I.

Date: NOVEMBER 6, 2013

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WHY IS QOL SO IMPORTANT?

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WHY QOL?

• People like to feel good• Helps get through cancer treatment• Allow patients to complete courses of chemo or

radiation without delays• Patients require less chemo and make fewer ED

visits• May prolong survival:

– Quality of life parameters such as pain, physical function and appetite loss can be predictive of better outcomes, including survival

– Study on stage IV lung cancer: those on QOL care lived longer, spent less time in the hospital and had a better QOL

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QOL FACTS

• In U.S., 30-50% of the 1.5 million people diagnosed with cancer will experience unrelieved suffering

• 70-90% of the 500,000 patients with advanced cancer will experience unrelieved suffering

• Less than 1/3 of oncologists have adequate training in QOL (ASCO 2011)

• Even if they are, doesn’t guarantee that QOL will be addressed or addressed adequately

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WHAT ARE THE ISSUES?

OTHER CONDOTIONS AFFECTING CANCER

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OTHER MEDICAL CONDITIONS AFFECTING CANCER AND CANCER TREATMENT

• Infection, High blood pressure, COPD, Heart disease, renal insufficiency increase mortality >50%

• DIABETES– Poor infection control and healing

• SMOKING– Prevents full dose chemo to affect tumor

• ALCOHOL– Affects liver metabolism

• SLEEP– Sleep apnea

• PAIN (non-malignant)– Physiological stress to body and mind

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NON-CANCER MEDICATIONS THAT CAN HELP FIGHT CANCER

• MELATONIN (Sleep)– In high dose (>20 mg), can help chemo and radiation kill

more tumor cells

• METFORMIN (Diabetes)– Has anti-tumor properties– Take even if you use insulin

• STRONTIUM (Osteoporosis)– Makes new bone and strengthens bone

• POTENTIALS:– Aspirin

• Cancer prevention, recurrence and metastases– Breast, prostate, colon so far

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WHAT ARE THE ISSUES?

SIDE EFFECTS OF CANCER AND IT’S TREATMENT

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THE MOST COMMON QOL ISSUES

• Pain (89%)• Nausea & Vomiting

(60%)• Fatigue (61%)• Weakness (66%)• Sleep• Anorexia (66%)• Early Satiety (51%)• Weight Loss• Constipation• Neuropathy

• Anxiety/Depression• Edema/Lymphedema• Wound healing• Skin rashes/lesions

– Hand-foot syndrome

• Radiation problems– Swallowing

problems– Dry mouth (57%)– Altered taste

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COMPLEMENTARY METHODS FOR QOL IN CANCER

CHINESE MEDICINE

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USES OF ACUPUNCTURE FOR CANCER

• Nausea and vomiting• Pain

– Inflammatory, Nerve, Spinal, Visceral (Organ)

• Neuropathy• Fatigue• Stress/Anxiety• Hand-foot syndrome and other skin reactions from

chemo• Salivation/taste problems• Vasomotor symptoms (hot flashes, sweats)• Co-morbidities: QOL (i.e., allergies, asthma,

incontinence, IBS, etc)

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CHINESE HERBS: GENERAL PRINCIPLES

• Most are formulas working synergistically to produce effects– Address four different aspects

• Can be used with chemo/radiation• Downsides:

– Must take more pills– Should be discontinued 1-2 weeks before surgery– Be careful of contamination or adulteration

• Avoid “secret” ingredients• Look for “Made in USA” (or Canada)

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USES OF CHINESE HERBS FOR CANCER

• Immune modulation– Coriolus (Turkey Tail)

• Stimulates production of killer T-cells and Tumor Necrosis factor

• Increases survival rate• Use as adjunct to chemo/radiation

– Mushrooms: • Reishi, tremella, poria, maitake: anti-tumor polysaccharides• Polyporus: decreases recurrences of bladder cancer after

surgery• Agaricus: Beneficial in gynecological cancers

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USES OF CHINESE HERBS FOR CANCER, cont

• Fatigue– Mushrooms (Ganoderma, Poria, Reishi, polyporus)– Ginseng: American, Panax– Zuo Gui Wan/You Gui Wan (Astra Essence)

• Overall tonic• Adjunct to chemo/radiation• Speeds recovery from surgery

• Anxiety– Ding Xin Wan (Calm Spirit)

• Potentials:– Ba Zhen Tang (Eight Treasures): Increase blood cells– Bao He Wan (Quiet Digestion): Nausea

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QiGONG/TAI CHI

• Qi= energy Gong=ability• QiGong basis of Tai Chi• Combines exercise with breathing and meditation• Studies show positive effects, including efficiency

of immune cells; works on body and brain• Excellent for fatigue, stress• 3000 QiGong prescriptions

– 15 min-4 hours– Any age or functional status– Chi Lel recommended

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COMPLEMENTARY METHODS FOR CANCER

HERBS AND SUPPLEMENTS

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ANTI-TUMOR HERBS AND SUPPLEMENTS

• Green tea– (4 cups/day; 240-320 mg polyphenols): general inhibition

of cancer

• Ellagic Acid (200 mg daily)– Anti-tumor properties

• Fish oil (>1500 mg daily)– Stimulates appetite, maintains weight– May enhance tumor cell sensitivity to cancer treatment

• Flaxseed Oil (2 tsp daily, freshly ground)– May deter prostate cancer growth

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ANTI-TUMOR HERBS AND SUPPLEMENTS, cont

• Curcumin: Turmeric extract (36-180mg curcumin)– Simultaneously counters 10 discrete causative factors in

cancer development– Intervenes at each stage in sequence of events that

enable cancer cells to develop, proliferate and metastasize

• Resveratrol (20mg of the natural 50% trans type)– Anti-inflammatory and immune system boost

• Vitamin D– Lab and cell culture studies show inhibition of growth

and spread of tumors– Need levels between 40-60 ng/ml– Use D3 not D2

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Herbs and Supplements to Reduce or Prevent Side Effects

• “Chemo” Brain – Gingko biloba (240 mg daily)– Ketogenic diet (Paleolithic)

• Probiotics– 70% immune system in GI tract– Helps balance GI system: diarrhea/constipation– C-dif infections (Saccharomyces)

• Honey– Antibacterial– Excellent for healing wounds– Mucositis/Stomatitis

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More…..

• Nausea– Ginger (1 gram daily): tincture best– Peppermint Oil (180-225 mg three times daily)

• Dermatitis– Calendula lotion– Chamomile skin cream– Lavender essential oil

• Insomnia– Melatonin (20 mg at night)– Valerian (400 mg)

• Vasomotor symptoms– Black cohosh (20 mg daily)

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And more….

• Fatigue– L-carnitine (6 grams daily)– Licorice (DGL: 300-400 mg extract three times daily)– Siberian ginseng (400-1200 mg daily)– Alfalfa tea (5-10 grams daily)– Oatstraw (3-5 ml three times daily)– Ashwaghanda (1-6 grams daily)

• Also increases blood cell counts

• Heart protection– CoQ10 (240 mg daily)

• Don’t use during radiation

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MORE COMPLEMENTARY METHODS FOR CANCER

“COLD LASER”

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HOT VS COLD LASERs

• Hot Lasers:– Cut, coagulate, vaporize

• Cold Lasers (LLEL)– Repair, Regenerate, Accelerate healing

= photo-bio-activation

– Does not affect normal tissue

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LASER PENETRATION

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CANCER CONDITIONS BENEFITED BY LLEL

• PAIN– Inflammatory– Trigger points– Radiation burns

• NERVE CONDITIONS– Neuropathy and other damaged nerves– Shingles infections and sequelae

• WOUND HEALING– Post-surgical– Decubiti

• LYMPHEDEMA• FATIGUE• MUCOSITIS/STOMATITIS

– Salivation, taste, cheilitis

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OTHER CONDITIONS BENEFITED BY COLD LASER

• Neck/back pain– Ruptured or degenerative discs– Sciatica

• Compressive neuropathies• Dental Pain• TMJ• Joint arthritis• Plantar fasciitis• Shingles

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MORE COMPLEMENTARY METHODS FOR CANCER

“MIND-BODY MEDICINE”

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MIND-BODY MEDICINE

• Can change the expression of genes

• Meditation• Relaxation• Prayer• Support groups• Imagery

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THINGS TO KNOW ABOUT SPECIFIC QOL PROBLEMS

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PAIN STATISTICS

• < 1/3 of oncologists are appropriately trained in pain management

• <50% cancer patients obtain adequate relief: 65% if minority; less in women and older

• Under-treatment, non-treatment or inadequate Rx• Question of addiction

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THINGS TO KNOW ABOUT PAIN TREATMENT

• Opioids: taking 1-3 together better than one at a time

• If opioids not decreasing musculoskeletal pain, an anti-inflammatory (NSAID) may help

• Neurontin (gabapentin) for nerve pain should be started very slowly and gradually increased over 2-3 weeks

• Acupuncture and laser excellent adjuncts

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THINGS TO KNOW ABOUT NAUSEA AND VOMITING

• Large variety of medications: MUST find cause– Central: compazine– GI: Phenergan, Zofran/Kytril– Emptying: Reglan (metoclopramide)– Antipsychotics (Zyprexa)

• Acupuncture very helpful

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THINGS TO KNOW ABOUT FATIGUE Caused by cancer and cancer Rx

• Comes on suddenly, doesn’t result from activity or exertion, not relieved by rest or sleep

• Radiation: cumulative fatigue• May last for years/decades• r/o anemia, thyroid, nutrition• Can be caused by depression, stress or pain• Best treatments are complementary:

– Acupuncture– Chinese herbs: Zuo Gui Wan (Astra Essence), Ginseng

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ANXIETY/DEPRESSION

• Chronic stress works as a “fertilizer” to feed cancer progression through inflammatory signaling

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ANXIETY AND DEPRESSION TREATMENT

• Conventional Rx– SSRI’S: Escitalopram (Lexapro) preferred– Remeron: sleep and depression/anxiety– Xanax, Ativan

• Alternative– Mind-Body (Meditation, Interactive Imagery)– Chinese herbs: Ding Xin Wan (Calm Spirit)– Acupuncture

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THINGS TO KNOW ABOUT CONSTIPATION

• Occurs in greater than 50% of cancer patients• Should have a BM within 3 days• Best combo: Dulcolax + senna• Best enema: Milk and Molasses• Complementary Methods

– Acupuncture– Probiotics– Black Cherry/Prune juice– Smooth Move Tea (Senna + Licorice Root, Bitter Fennel

Fruit, Organic Sweet Orange Peel, Organic Cinnamon Bark, Organic Coriander Seed, Organic Ginger Rhizome, Orange Peel Oil on Gum Arabic)

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THINGS TO KNOW ABOUT SWELLING

• EDEMA (Swelling in limbs)– Spironolactone (Aldactone) preferred: 100-400 mg daily– Loop diuretics can be added (Lasix): 40-160 mg daily– Ratio 100:40 limits low potassium

• LYMPHEDEMA– Occurs in about 20% of breast cancer patients after

axillary dissection and/or radiation– Can occur in legs from inguinal lymph node treatment– Cold laser can help even years after

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THINGS TO KNOW ABOUTNeuropathy

• Most neuropathy will resolve in 1-4 years

• Conventional– Medications: gabapentin (Neurontin), pregabalin (Lyrica)

• Alternative– Electrical stimulation; H-wave– Acupuncture– Low level energy laser

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THINGS TO KNOW ABOUT WOUND HEALING

• Poor wound healing common in cancer patients:– Zinc– Low level energy laser– Medi-honey

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THINGS TO KNOW ABOUT WEIGHT LOSS

• It is estimated that 67% of cancer mortality is related to poor nutrition

• Significant number of patients die from malnutrition rather than their cancer

• Prealbumin best test to determine adequate nutrition (>18)

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EATING ISSUES INTERFERING WITH NUTRITION

• No appetite• Nausea and vomiting• Constipation• Mucositis/stomatitis• Getting full too quickly (early satiety)• Taste problems• Swallowing problems• Decreased saliva

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Eating potpourri

• Organic food no more nutritious than non-organic– Has pesticides, but can wash them off

• Chocolate lowers BMI and can lower stroke risk; also helps thin blood

• Fiber-fortified foods tend not to be as nutritious as unprocessed foods

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EXERCISE IN CANCER

• During treatment, improves physical functioning, fatigue and multiple aspects of QOL (bone health, muscle strength)

• Increased survival and reduced morbidity in colon cancer

• May need lower intensity if previously sedentary or due to treatment

• Balance and safety factors with bone loss, neuropathy• Aim: 150 minutes per week, as vigorous as tolerated• Strength training at least 2 days per week• Pelvic floor exercises for incontinence (50% reduction)

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THINGS TO KNOW ABOUT SLEEP

• Important for regeneration, protection of normal tissues, immune system, fatigue

• Sleep apnea: increases mortality fivefold• Melatonin: High doses have anti-cancer effect• Valerian: Decreases “too many thoughts”

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MARITAL STATUS

• Study revealed that married patients have earlier diagnosis, complete treatment better and have longer survival– Men benefit more than women

• Solutions:– More support for un-marrieds– Also need support for caregiver: often ignored

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POTPOURRI

• Air fresheners emit potentially harmful chemicals: this includes “green” ones

• Breast or Ovarian cancer patients: Avoid “youth enhancing”, “rejuvenating” creams: contain estrogen.

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QOL DURING SURVIVORSHIP

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RECOMMENDATIONS TO PREVENT OR DELAY RECURRENCE

• The best advice to reduce recurrence is exercise and maintain a healthy diet

• Control co-morbidities– Levels of metabolic factors can influence cancer growth

pathways• Diabetes, HBP and obesity all related to increased rate of

recurrence and decreased survival in breast cancer• Elevated insulin: insulin-like growth factor (IGF-1) stimulates

mitosis and inhibits apoptosis

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PAY ATTENTION TO OVERALL HEALTH

• Nearly half of cancer survivors die of something else other than cancer– More likely the longer the survival

• Clinicians and patients pay less attention to the prevention and treatment of other diseases and complications*

• A significant number of cancer survivors have poor health behaviors (AJCO, Feb 2012)– More weight gain, smoking, less exercise– Cervical ca more smokers, drinkers, more obese

• *American Assoc for Cancer Research Annual Mtg, 2011

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DIET

• Choosing healthy carbohydrates• Wise protein choices• Increasing “good fats”- olive oil, nuts, coconut oil• Eats lots of high nutrient density vegetables and

fruit• Exercise

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DIET, cont

• Carbohydrate:Protein Ratio 2:1• Protein: 2/3 plant based• Carbohydrate: Low glycemic index

– Avoid hyperinsulinemic response: Insulin spike > increases growth factors

• Mediterranean diet considered the best

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TAKE HOME MESSAGE

• In this day and age, no one needs to suffer.

• There are a variety of both conventional and alternative methods that can improve quality of life

• You may have to be the one who insists on treatment or find your own

• Survivors need to pay attention to other medical conditions and maintain good habits, diet and exercise