Breast Cancer

Integrative breast cancer care has a remarkable amount to offer you. It can add to your treatment, help with side effects, benefit your quality of life, help you get well again, and reduce your risk of recurrence. Psychologically and spiritually, it can have transformative effects.

Let’s be clear: integrative cancer care means skillful choices in both conventional and complementary cancer therapies.

The very first step is deciding what your goals are. Your goals will guide you in choosing both conventional and complementary therapies. No matter what conventional therapies you choose, our 7 Healing Practices can be beneficial in many ways—physical, emotional, mental and spiritual. They are the foundation to strengthen you for rigorous conventional therapies, reduce side effects, build health and help reduce the risk of recurrence.

Beyond the 7 Healing Practices you will find many specific integrative therapies to explore. Don’t let the number of choices deter you. We’ve arranged them in an easy order to consider, starting with those with the greatest safety, efficacy, and ease of access. Also, don’t overlook our special category of Off-label, Overlooked or Novel Cancer Approaches (we call them ONCAs). They have a lot to offer even if lifestyle changes seem too hard at this point.

I’ve known quite a few 20-year survivors of metastatic breast cancer—and I have known hundreds of women who have far outlived a metastatic prognosis.

We hope to help you live as well as you can for as long as you can with the optimal combination of conventional and complementary therapies. We hope to help you find a way to integrate the therapies that serve you best. That is how the best integrative oncologists do it—and we wish the best for you. Take it slow. Start with the simple things, like our seven healing practices, and move slowly toward the more complex decisions.

Don’t try to take all this in one bite. Take small bites, and come back as you are ready for more.

If the diagnosis is wrong, the treatment is often wrong. Many oncologists recommend a second independent reading of your pathology report—preferably from outside your medical center. Some cancer centers do this routinely, especially if they are not certain of the reading.

Further diagnostic tests (see at right), can inform your treatment. They may also help you choose the complementary therapies that may enhance your conventional treatment, help minimize side effects and improve your quality of your life.

You can also prepare yourself for what to expect. You can anticipate side effects and work to minimize them even before treatment starts. Learning what to expect helps you prepare to build your resilience for conventional treatments in the weeks and months to come.

Like conventional therapies, complementary therapies are best explored with a health professional experienced with these therapies. You may want to bring this BCCT Breast Cancer Handbook with you to discuss with your health professional.

Simple complementary and integrative approaches can improve outcomes with breast cancer. More complex approaches can be considered as you get further into your research. We cover both.

Within one year, the American Society for Clinical Oncology (ASCO) endorsed these guidelines. See the ASCO endorsement in Integrative Therapies During and After Breast Cancer Treatment: ASCO Endorsement of the SIO Clinical Practice Guideline.

The SIO reviewed randomized controlled trials published between 1990 and 2015. Researchers were looking at “the use of integrative therapies for specific clinical indications during and after breast cancer treatment, including anxiety/stress, depression/mood disorders, fatigue, quality of life/physical functioning, chemotherapy‐induced nausea and vomiting, lymphedema (swelling), chemotherapy‐induced peripheral neuropathy, pain and sleep disturbance.” Recommendations from this review:⁴

• Music therapy, meditation, stress management and yoga for anxiety/stress reduction
• Meditation, relaxation, yoga, massage and music therapy for depression/mood disorders
• Meditation and yoga to improve quality of life
• Acupressure and acupuncture for reducing chemotherapy-induced nausea and vomiting
• A lack of strong evidence supporting the use of ingested dietary supplements or botanical agents as supportive care and/or to manage breast cancer treatment‐related side effects

When these guidelines were presented at the 2017 SIO annual meeting, integrative oncologist and BCCT advisor Donald Abrams, MD, pointed out that the guidelines seemed conservative and that experienced integrative oncologists are safely and effectively using evidence-informed therapies that were not included in the SIO recommendations, such as some nutraceuticals and botanicals in advanced breast cancer.⁵

The presenter replied that these guidelines are more conservative because only randomized controlled trials were reviewed, and the guidelines are intended to serve the wider audience of oncology clinicians who are not necessarily specialized in integrative oncology care. Dr. Abrams reminded the audience that lack of evidence of effect is not the same as evidence of no effect, and that the safer the therapy that has plausible basis for benefit, the lower the burden of proof.

Guidelines from other organizations are listed at right.

Programs and Protocols Specific to Breast Cancer

• Alschuler & Gazella complementary approaches⁶
• Block program⁷
• Chang strategies (case study)⁸
• Cohen & Jefferies risk reduction⁹
• Lemole, Mehta & McKee breast cancer protocol¹⁰
• MacDonald breast cancer program¹¹
• McKinney breast cancer protocol¹²

Traditional Medicine Systems

Traditional Chinese Medicine

Traditional Chinese medicine (TCM) uses botanical and animal products, trace elements, diet and exercise in addition to acupuncture/acupressure, which may be more familiar to many Western patients.

Most controlled studies of TCM in cancer investigate acupuncture. Several Chinese herbals show activity against human breast cancer cell lines in lab and animal evidence, with clinical evidence accumulating more recently. Examples:¹³

• The herb Scutellaria barbatae (About Herbs) promotes programmed cell death in patients with advanced metastatic breast cancer in a phase 1 trial.¹⁴
• Chinese herbs for breast cancer improved nausea, vomiting and fatigue in a review of randomized trials.¹⁵
• Green tea, commonly used in Chinese medicine, is associated with a lower risk of breast cancer and recurrence, with some evidence of therapeutic effects.¹⁶

Ayurvedic Medicine

According to BCCT advisor Debu Tripathy, MD, no formal studies have evaluated Ayurvedic medicine as a system approach in breast cancer. However, some of the herbs used in Ayurveda—such as curcumin (turmeric) and withafarin A¹⁷ —have shown activity against breast cancer cell lines in lab studies.¹⁸

A number of integrative oncology care programs and clinics employ complementary approaches to enhance conventional treatment and/or minimize side effects. Three programs have published studies of their integrative approaches in caring for those with advanced breast cancer. We provide a description of their research, not as endorsements of their programs, but as examples of different integrative approaches to advanced breast cancer care.

The Block Center, founded by Keith Block, MD, an integrative oncologist and BCCT advisor, offers a comprehensive cancer treatment program combining conventional treatments—often delivered in novel ways, such as according to circadian rhythms—along with nutrition and supplementation, fitness and mind-spirit instruction. The program is highly individualized and provides care to people with any kind of cancer.

A collaborative research group looked at survival data for a consecutive case series of 90 women with advanced metastatic breast cancer who received this comprehensive treatment program at the Block Center. Findings:²⁰

Despite a higher proportion of younger and relapsed patients, survival of metastatic breast cancer patients at the center was approximately double that of comparison populations and possibly even higher compared to trials published during this period. Explanations for the advantage relative to conventional treatment alone may include the nutritional, nutraceutical [relating to foods with medicinal properties beyond their nutritional value], exercise and psychosocial interventions, individually or in combination; self-selection of patients cannot be ruled out.

The researchers propose that the doubling of survival in those treated with the integrative program may be physiologically based and not due to self-selection. For example, patients in this program followed a low-fat diet, demonstrated in randomized controlled trials to improve relapse-free survival. Other specific program elements that may have helped with either prolonged survival or treatment tolerance:

• Increased intakes of antioxidants and phytochemicals
• Improved body composition and weight reduction due to increased exercise
• Reduction of stress hormones with mind-spirit interventions
• Higher intakes of vegetables, fiber and omega-3 fatty acids

The Block Center program also evaluates and supports a patient's quality of life and mental/spiritual responses to cancer and treatment. “Systematic training is provided in relaxation strategies, cognitive-behavioral interventions, and other approaches to enhance coping skills, pain management and sleep hygiene in order to manage the challenges associated with a cancer diagnosis and to mitigate side effects of chemotherapy, while improving treatment tolerance.”²¹ Being able to tolerate treatment better also means that women may be able to complete the treatment, improving their response and benefits.

The Block Program is explained in great detail in his patient-friendly book: Life over Cancer: The Block Center Program for Integrative Cancer Care.

Naturopathic oncology care is complementary rather than alternative to conventional care, with complementary therapies used in conjunction with conventional treatments. Naturopathic oncologists are oriented to deliver integrative oncology care in tandem with their conventional oncology colleagues. For more information, see our discussion of naturopathic medicine and oncology at Integrative Medical Systems in Practice in the US and Canada.

BCCT advisor Leanna Standish, ND, is a Fellow of the American Board of Naturopathic Oncology (FABNO) and works within the research institute of the prestigious naturopathic school Bastyr University. Dr. Standish has been leading research studies looking at integrative therapies that naturopathic oncologists provide, as well as the costs and outcomes of that care.

In one study published in 2017, the Bastyr Integrative Oncology Research Clinic (BIORC), in collaboration with Fred Hutchinson Cancer Research Center, followed 324 women of all stages of breast cancer who received integrative oncology care from board-certified naturopathic oncologists in the Seattle area. The most common integrative therapies prescribed:

• Trametes versicolor (turkey tail mushroom)
• Mind-body therapies
• Acupuncture
• Injectable therapy (mistletoe, vitamin B complex, IV vitamin C, IV artesunate and IV nutrition and hydration)

The costs ranged from $1594 per year for early stage breast cancer up to $6200 per year for stage 4 breast cancer patients. About 20 percent of that cost was out-of-pocket, with the remainder paid for by insurance or written off by the university. As the researchers point out, “regardless of the stage of breast cancer, integrative [naturopathic] oncology care is low-cost relative to conventional oncology costs. Standard cancer treatments may cost as much as $10,000 to $40,000 per month.”²³ The extra cost of adding complementary therapies to conventional care may be outweighed by the benefits to patients: better quality of life, symptom management and in some cases improved response to conventional treatment.

Since opening in 2009, BIORC has enrolled 704 patients in a separate prospective outcomes study treating breast, lung, colon, pancreatic, brain and skin cancers. One-third are patients with stage 4 cancer. During the study, the natural products used have been intravenous (IV) high-dose vitamin C, IV artesunate, oral curcumin, green tea and Trametes versicolor (turkey tail mushroom). Dr. Standish shared with us: “Our median overall survival was excellent compared to other published phase III clinical trials.”²⁴ Their results for breast cancer have not yet been published.

Dr. Ralf Kleef trained in Germany at an integrative-oriented medical school as well as at Sloan Kettering Cancer Research Institute in New York City as a postdoctoral immunology fellow. He has a clinic in Budapest, Hungary, which is on the “short list” of preferred European cancer clinics from Ralph Moss, a leading writer on integrative cancer treatments who publishes The Moss Reports.

Dr. Kleef uses what he calls “Lodoco” (low-dose combination therapy), the use of lower doses of chemotherapy and immunotherapy in combination with complementary therapies such as hyperthermia  and artemisinin. He uses chemosensitivity and molecular testing to identify which drugs and natural products are more likely to be active against an individual’s cancer.

In addition to using his integrative approach with people with minimal residual disease, he is also getting early promising results in people who were previously heavily treated for cancer and come to him with stage 4 disease.

Dr. Kleef co-authored and published a case study of a woman with stage 4 triple-negative breast cancer with lung metastasis. Kleef treated this 50-year-old woman with low-dose immune checkpoint inhibitors, hyperthermia and interleukin-2. According to Kleef, “She went into complete remission of her pulmonary metastases with transient WHO I-II diarrhea and skin rash. The patient remained alive for 27 months after the start of treatment, with recurrence of metastases as a sternal mass, and up to 3 cm pleural metastases.” Kleef acknowledges that this is only one case, and urges further research using this protocol, which consists only of [European] approved drugs and treatments.²⁵

Several individuals who have been treated at Kleef’s clinic have reported to us their favorable experiences, including patient advocate and breast cancer survivor Lindsay McDonell, although. See her story: Lindsay McDonell: Diagnostic Testing.

See the Moss Reports for a more thorough description of Dr. Kleef’s program: Moss Reports (purchase required), and Dr. Moss's blog post: Lower-dose immune drugs as effective as higher doses.

The foods you eat, plus how they're grown and prepared, have a substantial impact on your body terrain.

Key Points on Healthier Dietary Patterns

From Eating Well, Mediterranean Diet, and The Ecology of Breast Cancer (and other sources as noted):³¹

• Beginning in childhood, emphasize eating fruits and vegetables, especially leafy greens and those that are deep orange or yellow.
• Limit total fat to 20 to 35 percent of dietary calories. Different types of dietary fat have different health impacts—see a discussion at right.
• Eat more foods containing omega-3s, especially marine sources containing EPA and DHA.
• Eat low-fat dairy products instead of high-fat options.
• Eat less red meat and avoid processed meats.
• Include traditional, whole-soy foods, including tofu, soy milk and fermented miso and tempeh³² in your diet, starting in childhood if possible (but not during infancy). Whole forms of soy are best, while infant soy formula, supplements and highly processed soy foods—such as soybean oil, textured vegetable protein or soy protein isolate used in processed foods—are not recommended.
• Limit refined carbohydrates such as white flour, white rice, juices and sugar. Favor complex carbohydrates from whole grains, beans, vegetables and fruits.
• Add seaweed (sea vegetables) to your diet.

"Women who more closely followed a diabetes risk-reduction diet both before and after a diagnosis of breast cancer had lower risks for breast cancer–specific and all-cause mortality when compared with women with less healthy diets or those who did not substantially modify what they ate following diagnosis."³³

Frequently consuming sugar-sweetened soda beverages was associated with higher overall and cancer-specific mortality among ER-positive but not ER-negative patients, and among women with higher body mass indices (BMIs). Overall mortality was higher among premenopausal but not post-menopausal women with higher consumption of sugar-sweetened beverages.³⁴

Dr. Keith Block recommends eating medicinal mushrooms, such as shiitake, but also writes: "It is difficult to obtain clinically meaningful quantities of mushroom phytochemicals from even the healthiest diet, which is why I recommend getting them in the form of extracts."³⁵ See Cooking Mushrooms: 5 Medicinal Mushrooms You Can Cook With for guidance on edible medicinal mushrooms.

Treating the Cancer

Several nutrient and food-preparation factors have been connected to reduced growth and spread of breast cancer. No single component has been found to clearly influence breast cancer development or outcomes.³⁶

• Fats and plant-based foods: A large prospective study following women for 19 years found that reducing fat to 20 percent of energy and increasing vegetables, fruits, and grains in the diet significantly increased survival after breast cancer diagnosis.³⁷
• Vegetables and fruits: Greater consumption of vegetables and fruits has been associated with lower mortality,³⁸ although a prospective Japanese study found than an animal-product diet was associated with a decreased risk of breast cancer morbidity among premenopausal Japanese women.³⁹
• Carotenoids: Higher baseline blood levels of carotenoids, such as beta-carotene and lycopene, are associated with improved outcomes following diagnosis and treatment.⁴⁰
• Soy: Large studies of breast cancer survivors confirm that eating soy in whole food sources (not supplements or highly processed foods) is not associated with increased breast cancer proliferation, doesn’t interfere with tamoxifen and appears to increase the effectiveness of anastrozole.⁴¹ Genistein, a soy isoflavone, inhibits angiogenesis (formation of blood vessels to suppy tumors).⁴² A large study of combined data on US and Chinese women found that postdiagnosis soy food consumption of 10 mg/day or more showed a tendency toward a reduced risk of breast cancer-specific mortality.⁴³ Soy food consumption has been associated with better breast cancer survival in other studies.⁴⁴
• Omega-3 fatty acids from fish oil: Women who had been diagnosed and treated for early stage breast cancer who had higher intakes of EPA and DHA from food had a dose-dependent reduced risk of all-cause mortality.⁴⁵
• Asparagine: The availability of an amino acid called asparagine strongly promotes metastatic potential of triple-negative breast cancer in animal studies. Restricting dietary asparagine reduces metastasis without affecting growth of the primary tumour.⁴⁶ Foods rich in asparagine include dairy, whey, beef, poultry, eggs, fish, seafood, asparagus, potatoes, legumes, nuts, seeds, soy and whole grains. Foods low in asparagine include most fruits and vegetables.⁴⁷

Reducing Risk

Eating a healthy diet that is low in fat and high in fruits and vegetables has been linked to a reduced risk of invasive breast cancer⁴⁸ and a 25 percent reduced risk of recurrence in post-menopausal women.⁴⁹ Consuming cruciferous vegetables such as broccoli, kale, Brussels sprouts, and cauliflower shows some evidence of reduced risk of breast cancer,⁵⁰ as does consuming fruits and vegetables with higher total antioxidant capacity.⁵¹ Note, however, that antioxidant supplements do not show the same benefit and may even raise risk of cancer or recurrence. See more in Natural Products below.

Another large study (Women’s Healthy Eating and Living study, WHEL) included pre- and post-menopausal women and combined low fat intake with higher levels of fruits, vegetables and fiber. It found no difference in breast cancer recurrence or mortality between groups.⁵² However, a subsequent meta-analysis, including a secondary analysis of the WHEL study, found a potential benefit of a reduced-fat diet on risk of recurrence, even though not on survival.⁵³

The meta-analysis includes a recommendation to look at overall dietary patterns as well as physical activity in regard to weight:⁵⁴

As weight gain is a common occurrence following breast cancer diagnosis, and survivors are at increased risk for comorbid conditions such as cardiovascular disease and diabetes, achieving a healthy weight through reductions in caloric intake and increases in energy expenditure through a combination of diet, exercise, and behavioral strategies is encouraged.

Another study involving a large cohort of breast cancer survivors found that maintaining a stable weight in the early years postdiagnosis was associated with the lowest overall mortality risk.⁵⁵

An investigation involving the Women’s Healthy Eating and Living study concluded that a diet with higher vegetable, fruit, and fiber and lower fat intakes than the five-a-day diet may reduce risk of additional breast cancer events, but only in women not experiencing hot flashes.⁵⁶

The American Cancer Society recommends a dietary composition of 45–65 percent energy from carbohydrate, 10–35 percent of energy from protein, and 20–35 percent of energy from fat. They emphasize reducing the diet's energy density by limiting portions of energy-dense foods, such as high-fat and sugary items, in addition to increasing intake of low-energy-dense foods, such as vegetables and fruits.⁵⁷

Nutrient and food-preparation factors connected to breast cancer:

• Micronutrients:
  • Carotenoids:
    • Higher baseline blood levels of carotenoids, such as beta-carotene and lycopene, are associated with lower breast cancer risk.⁵⁸
    • Lycopene is associated with a lower risk of estrogen-receptor-positive (ER+) and progesterone-receptor-positive (PR+) breast cancers in large, population-based studies.⁵⁹
    • Lycopene is associated with a lower risk of ER−/PR+ or ER−/PR− breast cancer in pooled analysis of prospective cohort studies.⁶⁰
    • Beta-carotene is associated with decreased risk in postmenopausal women with high alcohol intake.⁶¹
  • DHA and EPA: These two omega-3 fatty acids, found in fish and fish oils, may be associated with reduced risks of breast cancer⁶² and of reduced risk of additional breast cancer events in patients with early stage breast cancer.⁶³
  • Iodine: high consumption of this element in Japan compared to Western societies has been associated with the low incidence of benign and cancer breast disease in Japanese women.⁶⁴
• Milk and dairy products: High intake of low-fat dairy foods, especially skim/low-fat milk, was associated with reduced risk of breast cancer in premenopausal women. No association between intake of dairy products, calcium and vitamin D and breast cancer risk was seen in postmenopausal women.⁶⁵
• Trans fats: The link between trans fats and breast cancer risk is modest.⁶⁶ Consumption of trans fats is consistently associated with higher mortality from all causes.⁶⁷
• Omega-6 fatty acids: In most studies, although not all, higher amounts of omega-6 fatty acids compared to omega-3s are associated with higher risk of breast cancer. In many people, perhaps in part as a result of genetically determined fatty acid metabolism, a higher omega 6:3 ratio is associated with higher levels of inflammation.⁶⁸
• Food preparation: Charring food (such as on the grill or in a broiler) produces known carcinogens such as heterocyclic amines, which are associated with breast cancer risk.⁶⁹
• Green tea: Lower breast cancer recurrence is seen with intake greater than three cups per day; less consistent evidence regarding reduced risk of onset⁷⁰
• Soy: Eating traditional (whole) soy products is associated with lower breast cancer risk, and eating them in childhood is associated with even lower breast cancer risk than soy in adulthood.⁷¹ A large study of combined data on US and Chinese women found that postdiagnosis soy food consumption of 10 mg/day or more showed a significant reduced risk of recurrence.⁷² Other studies show lower recurrence of breast cancer with soy consumption, even among postmenopausal women treated with tamoxifen.⁷³ However, in HER2 positive breast cancer patients, soy consumption has been associated with a greater risk of recurrence,⁷⁴ and overexpression of genes that promote cell proliferation.⁷⁵
• Seaweed and edible mushrooms: Eating some varieties of seaweed⁷⁶ and mushrooms (maitake and reishi)⁷⁷ may be associated with lower breast cancer risk.

Optimizing Your Terrain

• Proanthocyanidins, found in berries and grapes, are associated with lower inflammation, a contributor to breast cancer risk.⁷⁸
• Refined carbohydrates and insulin sensitivity: Diets with excessive refined carbohydrates cause repetitive spikes in insulin and increase the risk of diabetes, which increases the risk of breast cancer. Elevated insulin levels also promote breast cancer. Improving insulin sensitivity in those with insulin resistance or elevated fasting blood sugar may be helpful not only in reducing breast cancer risk, but also in reducing risk of recurrence and breast cancer-related death in those diagnosed with breast cancer.⁷⁹

See Eating Well and chapter 3 of Dr. Ted Schettler's The Ecology of Breast Cancer: Diet, nutrition, and breast cancer.

From Moving More and The Ecology of Breast Cancer:

• The World Cancer Research Fund and the American Institute for Cancer Research both recommend 60 minutes of moderate-intensity or 30 minutes of vigorous-intensity exercise daily to reduce cancer risk. The American College of Sports Medicine recommends that healthy adults and cancer survivors engage in a minimum of 30 minutes of moderate-intensity exercise five days a week for health promotion.
• Even modest amounts of activity provide benefit, so starting slowly with lower intensity exercise and gradually increasing the intensity and duration is a good approach for people who have not been very active.
• Most studies show that the benefits of physical activity are heightened by increasing the activity level and duration.
• Sedentary living increases the risk of many diseases and earlier death. Prolonged sitting is unhealthy, regardless of physical activity levels at other times.

Patients may achieve higher fitness levels in a supervised program compared to a self-directed program.⁸⁰ A 2019 study found that scheduling exercise to accommodate cyclical variations in fatigue due to chemotherapy may increase adherence to supervised exercise.⁸¹ Medicine & Science in Sports & Exercise. 2019 Sep 4.

See Moving More and pages 173-174 of Dr. Ted Schettler's The Ecology of Breast Cancer for tips for meeting these exercise and movement recommendations.

Treating the Cancer

Moving—whether by formal exercise or by increasing daily activities such as walking, gardening or dancing—is associated with better treatment outcomes. “Most but not all studies show that women who regularly exercise after breast cancer treatment experience reduced all-cause and breast-cancer specific mortality compared to sedentary women over follow-up periods averaging four to eight years. In many studies, higher levels of physical activity or exercise before diagnosis are also associated with improved survival after diagnosis.⁸²

Breast cancer survivors who performed the equivalent of walking three to five hours per week at an average pace had a lower risk of death from breast cancer as well as death from any cause, whether before, during or after chemotherapy. Even lower levels provided benefit, especially important during treatment.⁸³ Another analysis from the same project found that engaging in at least 10 MET-hours per week of physical activity was associated with a 27 percent reduction in all-cause mortality and a 25 percent reduction in breast cancer mortality compared with women who were less active.⁸⁴ Ten MET-hours per week is represented by any one of these activities:⁸⁵

• 3½ hours of housecleaning
• 3 hours of brisk walking
• 2¼ hours of dancing
• 1 to 1½ hours bicycling 10-16 mph

Conversely, an investigation of the After Breast Cancer Pooling Project found that very low levels of physical activity (physical activity less than 1.5 MET hours per week) among cancer survivors was associated with a 22 percent increased risk of breast cancer mortality compared to those who had 1.5 or more MET hours per week.⁸⁶

Managing Side Effects and Promoting Wellness

• A study found that exercise improved patients' chemotherapy completion rate without causing lymphedema or significant adverse events.⁸⁷
• Regular exercise is beneficial in reducing fatigue and improving physical function after diagnosis and initial cancer treatment.⁸⁸
• Women with early stage breast cancer who were more active consistently reported lower levels of depression and increased quality of life five years after the intervention compared to those who were less active.⁸⁹
• Exercise combined with a healthy diet may increase benefit even more.⁹⁰
• A 2019 review concluded that Nordic walking—performed with walking poles similar to ski poles—had a significant and positive impact on a number of breast cancer symptoms including lymphedema, physical fitness, disability and morbid perceptions.⁹¹
• Physical activity interventions were effective in improving executive function and self-reported concentration during breast cancer treatment.⁹²
• A large prospective study of breast cancer patients enrolled in the Women's Health Initiative found that increasing levels of exercise before diagnosis was associated with a significant graded reduction in subsequent cardiovascular events in long-term survivors of primary breast cancer.⁹³  
• A study found that one year of football (soccer) fitness significantly improved bone mineral density, leg muscle strength, and postural balance in women treated for early-stage breast cancer.⁹⁴

Reducing Risk

• “Strong evidence shows risk reductions of 20 to 80 percent for postmenopausal breast cancer with increasing physical activity.” according to Dr. Schettler.⁹⁵ The evidence in premenopausal breast cancer isn’t as strong.
• Women who reported participating in at least seven hours of moderate or vigorous physical activity per week had an 18 percent lower risk of breast cancer in the Nurses Health Study, with over 16 years of follow-up. Further studies have found that lifetime physical activity was associated with lower risk of premenopausal breast cancer, while both cumulative and recent physical activity were associated with lower risk in postmenopausal women.⁹⁶
• Meeting physical activity guidelines both before diagnosis and after treatment was associated with a lower risk of recurrence two years after treatment. Increased activity, even if not fully meeting guidelines, showed benefit.⁹⁷
• A large 2019 analysis found that engaging in 7.5 to 15 MET-hours per week (about 2.25 to 4.5 hours of brisk walking) was associated with a lower risk of breast and other types of cancer.⁹⁸
• Research shows an increased risk of various kinds of cancers among inactive individuals compared to very active people. The strongest associations in women are with postmenopausal breast cancer and cervical cancer.⁹⁹ Greater activity levels are associated with a lower risk of breast cancer, even among women at higher genetic risk.¹⁰⁰

Optimizing Your Terrain

Inactive women with newly diagnosed breast cancer were enrolled in an exercise intervention for about a month after diagnosis and until undergoing surgery. Compared to women participating in a mind-body intervention control group, those exercising demonstrated significant upregulation of 18 unique pathways, including several implicated in immunity and inflammation.¹⁰¹

For a discussion of the many studies examining links between activity and breast cancer, see chapter 4 of Dr. Ted Schettler's The Ecology of Breast Cancer: Exercise, physical activity, and breast cancer.

As we discuss in Managing Stress, unusual or chronic unmanaged stress—and the subsequent alteration in stress biochemistry—can affect tumor growth and proliferation.

Treating the Cancer

In The Ecology of Breast Cancer, Dr. Ted Schettler suggests that chronic stress could speed the growth and development of an undiagnosed cancer.¹⁰²

Dr. Schettler points out that the most significant associations of reduced stress levels with better survival are in women who don’t have metastatic disease when they are initially diagnosed and treated. But even in those with more advanced breast cancer, stress reduction has been related to longer survival in some individuals.

Managing Side Effects and Promoting Wellness

Compelling evidence shows that stress reduction significantly improves quality of life after initial treatment of breast cancer and beyond.

Improved quality of life is clearly associated with stress reduction in women with all stages of breast cancer. In general, outcomes are more likely to improve when conventional therapy is combined with more comprehensive interventions that include stress reduction along with optimizing diet, exercise, sleep, and social support.¹⁰³

See Managing Stress and chapter 7 in Dr. Ted Schettler's The Ecology of Breast Cancer: Stress, social support, and breast cancer.

Many women diagnosed with and being treated for breast cancer report having sleep difficulties. Anxiety and side effects of treatment can lead to sleep disruption. A vicious circle of cancer symptoms and treatment side effects can build, leading to poor sleep quality. Poor sleep then causes or worsens other symptoms, including depression, fatigue and anxiety.

Managing Side Effects and Promoting Wellness

Sleep interacts with treatments to impact your quality of life, and it can affect your ability to rebound from rigorous treatments. Repeated chemotherapy treatments impair melatonin production at night, increasingly disrupting sleep cycles as treatment continues.¹⁰⁴ Strategies to improve disturbed sleep before starting chemotherapy may improve daily function.¹⁰⁵

Many complementary therapies can help improve sleep and subsequently improve symptoms and quality of life. For instance, mind-body practices such as mindfulness meditation, tai chi and stress reduction practices have been found not only to improve sleep, but also to improve fatigue and depression in women with breast cancer.¹⁰⁶

Reducing Risk

An extensive meta-analysis did not find an overall association between ever-exposure to night-shift work and the risk of breast cancer.¹⁰⁷ However, considerable evidence shows that longer durations of shift work or rotating between night shifts and day or evening shifts is linked to higher risk of breast cancer.¹⁰⁸  

Optimizing Your Terrain

Beyond affecting normal cortisol rhythms, chronic poor sleep can disrupt many other processes and conditions with the internal terrain, fostering cancer growth and spread.

One of the problems of sleep disruption is that rhythms of the stress hormone cortisol are thrown off target. These abnormal rhythms are linked to less active natural killer cells, which is associated with shorter survival in those with breast cancer.¹⁰⁹

Consistently poor sleep (and even too much sleep) can lead to a host of physical, mental and emotional problems. Several of these problems create an internal environment that is hospitable to cancer development, growth and spread, such as these:

• Increased inflammation
• Weakened immunity
• Insulin resistance

Tai chi can reduce inflammatory markers in breast cancer survivors with insomnia. Inflammation is a risk factor for cancer.¹¹⁰

Sleeping well is an often overlooked but incredibly important way of keeping yourself healthy and reducing your risk of disease.

See Sleeping Well.

Exposures to toxic chemicals, light at night, radiation and electromagnetic fields are all associated with breast cancer.

Treating the Cancer

Lifetime cigarette smoking is associated with a poor prognosis among women diagnosed with breast cancer, and with breast cancer-specific and all-cause mortality.¹¹¹

Night shift work is associated with tumor growth: “Women who have breast cancer should be advised not to work night shifts because of the strong experimental evidence showing that suppression of melatonin secretion can facilitate tumor growth.”¹¹²

Radiation to treat cancer can increase risk of a second cancer in vulnerable healthy tissue that falls in the treatment field. Some integrative oncology clinicians recommend specific complementary approaches to prevent or minimize ionizing radiation damage to normal cells from imaging or radiation therapy.

• Naturopathic physician Neil McKinney has a protocol using “radio-protectant” natural products.¹¹³
• Dr. Keith Block discusses using radiation couplers to minimize damage to normal cells while enhancing killing effects on cancer cell.¹¹⁴

Reducing Risk

Chemical Exposures

Many toxic chemical exposures throughout the lifespan—starting with fetal development—increase the risk of breast cancer. For instance, exposing a fetus to the hormone DES increases breast cancer risk decades later, as does pre-pubertal exposure to the pesticide DDT, including exposures in utero.¹¹⁵

According to a report from the Institute of Medicine, the strongest evidence indicates the following chemical exposures increase breast cancer risk:¹¹⁶

• Combination hormone therapy products (see more below in Reducing Risk)
• Current use of oral contraceptives (increased risk may disappear within a few years after use is discontinued¹¹⁷ )
• Tobacco smoking

Increasingly persuasive evidence links the following chemical exposures to breast cancer risk:

• Passive smoking
• Organic solvents besides ethanol
• Ethylene oxide
• Polycyclic aromatic hydrocarbons (PAHs)
• 1,3 butadiene
• Some agricultural chemicals

See chapter 5 of Dr. Ted Schettler's The Ecology of Breast Cancer: Environmental chemicals, contaminants, and breast cancer.

Living in areas with high levels of fine particulate matter, which is defined as particles smaller than 2.5 micrometers, or PM2.5, is associated with a breast tissue condition that increases risk of breast cancer.¹¹⁸

Creating a Healing Environment describes specific actions you can take to improve your environment and reduce harmful exposures. You can also find recommendations on pages 176-180 of The Ecology of Breast Cancer.

Night Work and Light at Night

Shift work that disrupts circadian rhythms has been classified as probably carcinogenic by the International Agency for Research on Cancer (IARC).¹¹⁹ Working night shifts for 20 years or more is associated with a significantly increased risk of breast cancer. The risk with shorter spans of night-shift work is still unclear.

Steps that night shift workers can take to minimize circadian disruption, helping reduce cancer risk:¹²⁰

• Rapidly rotating shifts (one or two consecutive nights) cause less disruption of circadian rhythms than slowly rotating shifts (three or more consecutive shifts).
• Delay of circadian phase (scheduling sleep to start later) causes less disruption than advance of circadian phase (scheduling sleep to start earlier). Therefore, forward- rather than backward-rotating shifts are preferable. For example, scheduling work start times progressing later into the day or night—8pm, then midnight, then 6am—is less disruptive that start times that become earlier: 6am, then midnight, then 8pm.
• Permanent night work is an option to avoid circadian disruption and may be feasible if a night-oriented rhythm during days off is maintained. However, this requires avoiding bright light during the day and making certain that sleep is adequate.
• Modified light intensity during work at night can help, such as working in bright white light to increase adoption of a night rhythm or in dim red light to prevent adoption. Dim red light suppresses melatonin less than bright white light, but with a trade-off in alertness that is critical for performing many tasks.
• People working at night should be especially attentive to maintaining adequate levels of vitamin D.
• Considering the potential risks and benefits, most analysts do not recommend earlier or more intensive mammography screening in women night shift workers.

Ionizing Radiation

Ionizing radiation is clearly established as a risk factor for breast cancer, although very few people, nor even many physicians, are aware of the association.¹²¹

Exposure to ionizing radiation from medical sources, including X-rays, CT scans and other medical imaging, is increasing.

On the other hand, a 2020 meta-analysis found that exposure to the sun more than an hour a day can be protective against breast cancer. The researchers state that "this effect can most likely be credited to the potency of UVB radiation for producing vitamin D in the skin."¹²²

Electromagnetic Fields

The International Agency for Research on Cancer (IARC) has classified both extra low frequency (ELF) and radio frequency (RF) electromagnetic fields as possibly carcinogenic in humans,¹²³ although the connection to increased risk of breast cancer is not yet clear.

Disturbing case reports of breast cancer in young women carrying cell phones in their bras are noted, but no systematic study of the association has been published. Several mechanisms for how EMFs could influence breast cancer risk have been proposed. Because of this potential risk, many sources propose erring on the side of caution and reducing exposure to ELF-EMFs.

See Creating a Healing Environment and chapter 6 of Dr. Ted Schettler's The Ecology of Breast Cancer: The electromagnetic spectrum and breast cancer: Sunlight and vitamin D; shift work, artificial light, and sleep; electromagnetic fields for tips for reducing exposures.

Treating the Cancer

Sharing love and support has been shown to substantially help reduce the stress response and improve outcomes in women with breast cancer.¹²⁴

A 2017 investigation of the After Breast Cancer Pooling Project found that larger social networks were associated with better breast cancer-specific and overall survival.¹²⁵

Managing Side Effects and Promoting Wellness

Some of the earliest and most pivotal studies of social support improving quality of life have been in women with breast cancer.¹²⁶

See Sharing Love and Support.

Treating the Cancer

Finding meaning and setting goals are associated with better outcomes. Results of some studies:

• A study of 578 women with early-stage breast cancer were assessed using the mental adjustment to cancer (MAC) scale. The researchers found a “significantly increased risk of relapse or death at five years in women with high scores on the helplessness and hopelessness category of the MAC scale compared with those with a low score in this category.”¹²⁷
• A small study of metastatic cancer of many types found extended survival among those who scored higher on these scales:¹²⁸
  • Ability to act and change
  • Willingness to initiate change
  • Participating in self-help work
  • Relationships with others
  • Quality of experience
• Another study of patients with many types of cancer concluded that longer-term survivors displayed a much higher degree of early involvement in their psychological self-help than did most of their nonsurviving peers.¹²⁹

Managing Side Effects and Promoting Wellness

Finding meaning, setting goals, allowing and accepting difficult emotions and connecting with spirituality are associated with better outcomes:

• Suppressing difficult emotions is associated with greater distress in those with breast cancer.¹³⁰
• A 2015 study found that a "meaning/peace factor of spirituality" was consistently associated with improved quality of life (overall, physical and mental).¹³¹

See Exploring What Matters Now.

Several therapeutic approaches show potential. However, because breast cancer is actually many individual diseases with different responses to treatments, the advice of a healthcare professional knowledgeable about integrative oncology therapies is crucial.

The therapies presented here are not necessarily singly or in combination the right supplements for you to use. This list is not a recommendation from BCCT. Refer to our summaries of each of these therapies to see uses in breast cancer, where to find dosing guidelines, cautions, and their use in integrative protocols, programs and systems. A licensed health professional experienced in integrative breast cancer care can provide valuable guidance in selecting therapies.

The National Comprehensive Cancer Network (NCCN) professional guidelines for breast cancer treatment provide enough treatment guideline scenarios to make your head spin. Fortunately, NCCN has provided patient-friendly guides in which you can look up your type and stage of breast cancer and see treatment options your doctors are likely to present to you. See "Further Clinical Practice Guidelines" in the box at right for links.

A few key points from these guidelines (links at right):

• Getting the diagnosis and the tumor characteristics right is absolutely key to figuring out the best conventional treatment approach. See Standard and Non-standard Diagnostic Approaches.
• According to breast cancer medical advocate and BCCT advisor Gwen Stritter, MD, the NCCN guidelines are really good for about 85 percent of primary [non-metastatic] breast cancers. Following the guidelines will result in response to treatment for those 85 percent of patients. Since early-stage primary cancer is likely curable by following the guidelines, the risk/benefit analysis does not favor straying from them.
• A conventional oncology doctor is not likely to stray from the NCCN guidelines.
• Although advanced breast cancer is incurable in most cases, steady improvements are seen in survival with standard therapies as well as the newer targeted agents. We at BCCT know of many women who have lived for years with recurrent or advanced breast cancer behaving like a chronic illness kept at bay at least in part by conventional treatment.

This is not to say that conventional treatments are magic bullets that get in there, destroy the cancer cells, and get out without being noticed. All these treatments—surgery, chemotherapy, radiation therapy, hormone therapy, immunotherapy—come with costs: physical, cognitive,¹³⁵ emotional, social, spiritual and financial. And they don’t work for everyone all the time.

Similarly, no complementary or alternative therapy is a suitable stand-alone treatment for breast cancer. Integrating the best of both evidence-based conventional and complementary therapy may be a sensible way to bolster the effects of conventional treatment and improve your tolerance to the side effects so you can complete your treatments. This integrative approach also makes sense for reducing the risk of recurrence after treatment and possibly extending your life, as described in sections below.

Ralph Moss’ free The Ultimate Guide to Cancer:™ Do-It-Yourself (DIY) Research shows you how to use four of the main tools that doctors use to decide on the best cancer treatments. It will help you learn why some cancer treatments that look good in clinical trials may not work for “real world” patients like yourself. It will help you answer two questions that the doctor may be hesitant to answer in the detail you need to decide about treatment:

• What are my chances of actually living longer if I use this treatment?
• What are the likely side effects, and how long will they last?

Another question to ask is "What are the risks if I delay treatment?" A review and meta-analysis in late 2020 confirmed that delaying breast cancer treatment by a month or more increases the risk of dying.¹³⁶

A starting place for the science and conventional therapies related to breast cancer:

• National Cancer Institute:
  • About Cancer
  • Breast Cancer—Patient Version
  • Breast Cancer—Health Professional Version
• Cancer.net: Breast Cancer
• Breastcancer.org

Strategies for Chemosensitivity Testing

Early Stage Breast Cancer

1. The NCCN guidelines that your oncologist will likely follow are really good for about 85 percent of primary (non-metastatic) breast cancers. Following the guidelines will result in an excellent response to treatment for those patients. Since early stage primary cancer is likely curable by following the guidelines, the risk-benefit analysis does not favor straying from them. But in the case where chemotherapy suggested by the guidelines is not likely to result in a significant treatment response, or if the chemo doesn’t work, it makes sense to order chemosensitivity testing. I usually allow for two failed guideline treatments in primary breast cancer before trying chemosensitivity testing. Occasionally, as in the case of a particularly aggressive breast cancer, I will order chemosensitivity testing after just one line of failed chemotherapy.
2. While chemosensitivity testing is very good at predicting what will work, it is best at predicting what will not work. After chemosensitivity testing, check your oncologist’s pick against your test’s ineffective list. If your oncologist’s choice is predicted to be ineffective, then share the test results and talk about using a different chemotherapy that is both in the guidelines and on the chemosensitivity effective list. 
3. Most estrogen-receptor positive (ER+) breast cancers are unlikely to respond to chemotherapy. They typically respond well to hormone therapies which, unfortunately, cannot be tested in most chemosensitivity platforms. However, a small number of ER+ tumors with high Ki67 values or that are clinically aggressive will respond to chemotherapy. These may also be good candidates for chemosensitivity testing.

Recurrent Local Breast Cancer

If a recurrent breast cancer is considered curable, the same cautions as for primary breast cancer apply. But in this case, consider chemosensitivity testing after just one line of failed chemotherapy.

Stage IV (Metastatic) Breast Cancer

In the case of metastatic breast cancer, sticking to the NCCN guidelines does not provide a cure. Consider doing chemosensitivity testing at the time metastatic cancer is diagnosed and use that as a guide for chemotherapy choices.

Where Your Oncologist Might Be Coming From

Very few oncologists in the US will do chemosensitivity testing right off the bat in primary breast cancer. It is possible that chemosensitivity testing results will suggest using a drug that is not in the NCCN guidelines. If the oncologist strays from the guidelines in this case, he/she could open themselves to malpractice lawsuits.

However, if you move forward with chemosensitivity testing and show the oncologist the results, he/she may follow them, especially if the guideline therapy is predicted to fail.

• Intermittent fasting: periodic fasting around the time of chemotherapy may sensitize cancer cells to chemotherapy while protecting normal cells.³²³ A further investigation found that a fasting mimicking diet (FMD) for three days prior to and during neoadjuvant chemotherapy led to radiologically complete or partial response more often than a regular diet. Moreover, no difference in toxicity was seen between both groups, even though dexamethasone was omitted in the FMD group. FMD significantly curtailed chemotherapy-induced DNA damage in T-lymphocytes.³²⁴ See Dr. Alschuler's comments in Commentary below.
• Ketogenic diet:
  • Clinical evidence is limited to case studies showing improvement or complete responses to ketogenic diets in combination with other therapies.³²⁵
  • In preclinical studies, a low-carbohydrate ketogenic diet slowed mammary tumor growth and increased tumor latency in mice,³²⁶ and this effect was increased when mice were also treated with metformin.³²⁷
  • Lab studies have found that human breast cancer cells with an enzyme capable of re-using ketone bodies used nearby ketogenic fibroblast cells to fuel their growth.³²⁸

• Hyperthermia:
  • Hyperthermia acts as a chemo- and radio-sensitizer and improves outcomes such as local control and overall survival.³²⁹
  • A 2001 review concluded that “randomized phase III studies performed in patients with breast cancer, malignant melanoma and cervical cancer have convincingly confirmed the increased efficacy of the combination of radiotherapy with local or regional hyperthermia in comparison with radiotherapy alone.”³³⁰
• Cryoablation:
  • Cryoablation uses needles to insert liquid nitrogen or a similar gas into tumors to freeze and kill cancer cells. It is typically used for small tumors that can't be removed surgically.³³¹ A clinical trial is investigating nonsurgical cryoablation as an alternative to surgery for early-stage, small breast tumors with low-risk features (low-grade, hormone receptor–positive, and HER2-negative). Most women in the trial received both cryoablation and supplemental therapy (endocrine therapy, adjuvant radiation, or chemotherapy). An average of about three years after treatment, only about 2% of women aged 55 and older had a cancer recurrence in a preliminary report.³³²

A diet designed to address fatigue in breast cancer survivors showed positive results in a small pilot study.⁵⁰⁷

Periodic or short-term fasting may reduce chemotherapy side effects (vomiting, diarrhea, fatigue and weakness).⁵⁰⁸  Integrative oncologist Dwight McKee, MD, has advised some of his chemotherapy patients to follow intermittent fasting during chemotherapy.

After diagnosis, some studies show that recurrence is higher in those having more than three or four drinks per week, particularly in postmenopausal women.⁵³⁴

The American Institute for Cancer Research states: “For cancer prevention, AICR recommends not to drink alcohol. However, our recommendations recognize that modest amounts of alcohol may have a protective effect on heart disease and type 2 diabetes. If you do drink alcohol, limit your consumption to no more than two drinks a day for men and one drink a day for women. Alcohol appears particularly harmful when combined with smoking.”⁵³⁵ The American Cancer Society's 2020 guidelines also state that no alcohol is best.⁵³⁶

An extensive 2018 review and systematic analysis goes even further, recommending no consumption of alcohol: “The level of consumption that minimises health loss is zero.”⁵³⁸

See Creating Healthy Habits.

Many organizations, including the University of Texas MD Anderson Cancer Center, recommend breastfeeding your infant for at least six months, and longer is better.⁵⁴⁰

These diet and metabolic therapies are associated with lower risk of breast cancer, as described on the linked summaries:

• Mediterranean Diet
• Intermittent fasting: Women with early-stage breast cancer who fasted less than 13 hours each night had an increased risk for breast cancer recurrence compared with those fasting 13 or more hours per night.⁶¹⁹

It is not surprising that there is a groundswell of support in some centers for giving anti-estrogens before surgery in women with ER+ breast cancer.⁶³⁵ This allows the patient and the oncology team to know whether a particular medication is effective against the breast cancer and, if it does not induce a partial or complete remission, allows switching to a more active treatment regimen before surgery.

I had tamoxifen before surgery for my ER+ breast cancer, and seeing most of my cancer disappear on MRI over the ensuing 6 months was very gratifying. Knowing the tamoxifen worked so well kept me highly motivated to continue it for the next 5 years.

Current discussion on implants involves subpectoral expander-based breast reconstruction. For many years, the standard has been to place the implants under the pectoralis major muscle (PMM), partially detaching that muscle. Although this implant position is thought to give a better cosmetic result, many women report problems due to partial injury of the PMM with subsequent muscular deficit, breast animation and postoperative pain.

Evidence supports another way to position breast implants: placing the implant above the PMM and covering it with a dermal matrix derived from pig tissue. The procedure is called prepectoral implant placement and complete coverage with porcine acellular dermal matrix (ADM). Evidence thus far indicates this procedure provides good cosmetic results.⁶³⁶ However, the use of ADM has been associated with higher rates of overall complications, seroma (a buildup of fluid where tissue has been removed), infection and reconstructive failure.⁶³⁷ You and your surgical team need to assess risks and benefits carefully.

An article in the New York Times provides a discussion of this procedure as well as describing Dr. Deborah Cohan's experience with replacing her sub-pectoral implant with a pre-pectoral implant: New approach to breast reconstruction may reduce pain and weakness for some.

See also Dr. Susan Love's book, Dr. Susan Love’s Breast Book. 6th edition, for an in-depth discussion of reconstruction options.

When planning for surgery, several decisions and actions can reduce the risk of postoperative complications. Such complications, including these, while not occurring in the majority of patients, do affect many:

• Infection
• Seroma (fluid collection in the surgical area
• Hematoma (blood collection in the surgical area)
• Reconstructive failure (loss of implant or flap)
• Pain

Of these complications, infection is one for which patient decisions and behaviors have a big impact. Also the type of surgery makes a difference—reconstructive procedures have a much higher complication rate than lumpectomy or simple mastectomy. We will be highlighting ways to avoid infection and the reconstructive techniques that are least prone to complication.

Most people are aware that complications from surgery cause increased hospitalizations and healthcare spending. But many are not aware that they can delay important time-sensitive adjuvant treatment such as chemotherapy or radiotherapy, resulting in worse survival.⁶⁴³ Complications also reduce patient satisfaction with the procedure itself and with the cosmetic outcome.

Fortunately, intensive study has found ways to reduce complications. Surgeons and patients now have a lot of information that will help them. First of all, it is important to know whether you or your surgical procedure have specific factors that increase your risks for problems.

The following patient characteristics and behaviors are associated with higher risk of postoperative complications:⁶⁴⁴

• Obesity, with a body mass index of 30 or higher
• Tobacco smoking
• Age 65 or older
• Hypertension
• Compromised immunity or inflammation
• Hyperglycemia (high blood sugar or poorly controlled diabetes)

Having more than one of these risk factors multiplies the risk of complications. Addressing one or more of these factors before surgery decreases complications. The overall complication rate is 12.6 percent for women older than 65 who choose immediate reconstruction after mastectomy, compared with 6.8 percent for those under 65.

Infection rates for breast reconstruction after mastectomy can exceed 30 percent.⁶⁴⁵ Postoperative complications are higher in these situations:⁶⁴⁶

• Immediate reconstruction following mastectomy
• Flaps (LD, TRAM or DIEP)
• Bilateral procedures
• Radiation therapy during or after reconstruction
• Chemotherapy

Of note, some institutions will strongly advise delaying reconstruction until after radiation therapy for those who currently smoke simply because performing an immediate breast reconstruction after mastectomy doubles the complication rate. 

Neoadjuvent or adjuvant treatments, such as chemotherapy or radiation (given prior to or after surgery) may not only increase the risk for infection but may also cause further tissue damage. If you need these treatments, talk with your doctor about the best timing of reconstructive surgery in relation to other treatments.⁶⁴⁷

Surgical infection rates vary considerably for different types of surgery, for different hospitals, and for different surgeons (or even with the same surgeon as he or she gains experience). Longer hospital stays are also associated with higher infection rates. Information on hospital postoperative infection rates can be found at Medicare.gov—Hospital Compare. Dr. Susan Love advises: "One thing that keeps people in the hospital after mastectomy is learning how to manage a drain. If possible, ask your doctor to show you and your family the drain and how to empty it at the pre-op visit."⁶⁴⁸

Antibiotic Use and Infection Rates

A systematic review in 2013 found that antibiotic prophylaxis for 24 hours following breast reconstruction reduced infection rates from 14.4 percent to 5.8 percent. No further benefit was found for continuing antibiotics past 24 hours.⁶⁴⁹

What You Can Do

• First, find out how much time you can take before surgery to develop a plan and prepare for surgery.
• Preparing your body
  • Discuss which risk factors you can improve before surgery and come up with a plan of actions to take. Actions may include controlling hypertension, stress, hyperglycemia and other conditions, or stopping smoking
  • Consider incorporating stress management practices in the weeks leading up to surgery. Many patients find imagery practices specific to preparing for surgery to be helpful. See Managing Stress, Stress, Mind-Body Approaches and Guided Imagery.
  • In addition to effective stress management practices, use emotional support, counselling and pre-surgery medication as appropriate to help reduce preoperative psychological stress.
  • If you typically clean an animal litter box or bird cage, find someone else to clean it before and for several weeks after your surgery.
• Optimizing your surgical context:
  • Check postoperative infection rates for the hospital where your surgery will be performed at Medicare.gov—Hospital Compare. While individual surgeon complication rates are available for many types of surgery, they are not published for breast surgery. Having said that, infection rates tend to be higher on average with less-experienced surgeons (a pretty good rule of thumb for having good experience is to consider surgeons who have done at least four per month of your specific type of surgery for five years).
  • Inform your surgical team of any supplements, herbs or other therapies you’re using prior to surgery.
  • If you have financial or social barriers to good pre- and postsurgical care, ask to be referred to an oncology social worker or oncology navigator for assistance.
  • Work with your surgeon to determine the timing of reconstructive surgery. If you’ll be receiving radiation or chemotherapy consider initiating those treatments before reconstructive surgery.
  • Schedule your surgery as an ambulatory procedure rather than as an inpatient hospital stay if possible.
  • Discuss your options for anesthesia, post-surgical pain control (see more about ERAS protocols below) and the steps in the column at right with your surgical team at the pre-op visit.
• Immediately before surgery:
  • Avoid presurgical dehydration.
  • See if you can postpone surgery if you develop a cold, flu, pneumonia or other infection shortly before scheduled surgery.
• After surgery
  • Before leaving the hospital, be sure you (and anyone who will be assisting you at home) fully understand and follow all wound care instructions carefully. Call your physician immediately if you show any signs of infection—an ncrease of redness, swelling, pain or discharge from your wound.
  • Avoid contact with soil for two or more weeks after surgery.
  • Avoid procedures that might introduce infection to the breast, such as nipple piercing or a tattoo.
  • Consult an integrative physician or licensed naturopath (preferably one who is certified in oncology) to recommend approaches to maintain healthy immune function to improve your wound healing and reduce your risk of infection.
  • In the weeks following your surgery, if you need a medical procedure that may introduce bacteria to the body, check with your surgeon about using antibiotics to prevent infection.

What Your Surgeon Can Do

• Assess all choices and optimize risk factors, including patient characteristics and their status of adjuvant therapy, such as radiotherapy and chemotherapy.
• Avoid textured implants due to a possible increased risk of anaplastic large-cell lymphoma.⁶⁵⁰
• Because half of infections occur more than 30 days after a procedure, implement a plan for follow-up care, including appointments and phone calls.
• Reduce suppression of the immune system induced by surgery and anesthesia⁶⁵¹
• Use regional anesthesia and IV propofol as the primary anesthetic when possible
• Provide adequate pain control throughout the surgical experience while minimizing the use of opioids such as morphine, oxycodone or codeine.
• Avoid opioids during or after surgery by using an intravenous propacetamol and anti-inflammatories such as ketorolac while in the hospital and then using oral anti-inflammatories such as ibuprofen or naproxen after discharge.
• Avoid hypothermia by maintaining core body temperature devices such as fluid warmers and external body warmers.
• Remove catheters and drains as soon as possible.
• Use antibiotic prophylaxis.

According to one national report,⁶⁵² 18 percent of opioid addicts or persistent users got their first opioid prescription after surgery. Evidence also shows that use may increase your risk of cancer recurrence.⁶⁵³ These are both good reasons to carefully consider whether use is necessary.

Fortunately, some hospitals are now discharging even their post-mastectomy patients without any opioids at all and, despite this, are achieving better pain control than with standard treatment that includes opioids. Maimonides Medical Center in Brooklyn, New York, is on the forefront of this movement, as discussed in their 2019 paper, Mastectomy is no longer an indication for postoperative narcotic.⁶⁵⁴ Many other hospitals are instituting their own opioid-avoiding protocols. Dr. Stritter strongly recommends that you ask your surgeon at the pre-op visit whether their hospital has a post-mastectomy opioid-sparing ERAS (Enhanced Recovery After Surgery) protocol. While we are in the throes of an opioid epidemic, it makes a lot of sense to minimize unnecessary opioid prescriptions.

In addition to pain control, some retrospective studies suggest that a single intraoperative dose of NSAIDs such as ketorolac may even reduce the risk of breast cancer recurrence.⁶⁵⁵ But a single dose may not be enough. 

Dr. Stritter, once interested in the idea of using such a protocol for breast cancer surgery, has come to a different conclusion. “The initial reports⁶⁵⁶ were based on retrospective, observational studies that had no control group.” Dr. Stritter’s confidence in those reports evaporated when Forget published her updated report—“a definitive prospective, randomized trial—at the 2018 San Antonio symposium that showed no effect of a single dose of intraoperative ketorolac on early recurrences.”⁶⁵⁷ Dr. Stritter thinks it doesn't make physiological sense that a single dose of ketorolac would reduce the chance of recurrence or metastasis. “The healing breast would have the epigenetic, genetic and proteonomic changes of wound healing—a well-documented pro-oncogenic environment—for several weeks until the incision has healed.” That is why after her bilateral mastectomy, Dr Stritter used anti-inflammatories (and no opioids) during her entire post-operative period, not only for pain relief but in hopes of creating an anti-oncogenic tumor microenvionment.

A 2018 review of anesthetic interventions in breast cancer concluded that “based on the available evidence, an ideal anesthetic in this patient population would involve a combination of TIVA (propofol), regional anesthesia (paravertebral block), non opioid sedatives (clonidine or dexmedetomidine), and COX-2 inhibition (ketorolac).”⁶⁵⁸

Non-drug measures that can reduce inflammation, pain and opioid use in cancer surgery:

• Acupuncture⁶⁶⁰
• Options with less published evidence regarding effectiveness.
  • Electroacupuncture⁶⁶¹ and transcutaneous electrical acupoint stimulation (TEAS)⁶⁶²  
  • Transcutaneous electrical nerve stimulation (TENS)⁶⁶³
  • Pulsed electromagnetic fields in most⁶⁶⁴ but not in all studies⁶⁶⁵

Also see our Integrative Approaches and Surgery page for further research on pain management in surgery for more types of cancer and other settings.

From medical advocate, breast cancer survivor and BCCT advisor Gwendolyn Stritter, MD

About 15 to 20 percent of patients have moderate to severe chronic pain after breast cancer surgery.⁶⁶⁶ Regional anesthesia (also known as nerve blocks) has been shown to reduce the risk of persistent pain after breast surgery⁶⁶⁷ Thoracic paravertebral blocks and PECS blocks are the two types of regional anesthesia most widely used.

Performing such nerve blocks before surgical incision allows for “light" general anesthesia (such as primarily using IV propofol instead of inhaled gases). This in turn results in quickly “waking up” from anesthesia without nausea or prolonged grogginess. Enough evidence shows that regional anesthesia lowers the chance of subsequent relapse and metastasis.⁶⁶⁸ A formal clinical trial is looking at this very issue: Regional Anesthesia and Breast Cancer Recurrence.

Not all anesthesiologists have the training or experience to do these blocks well. An appointment with the anesthesia team well in advance of surgery will increase the odds of getting these blocks before mastectomy. I had bilateral paravertebral blocks for my double mastectomy and required only oral anti-inflammatory medication for post-op pain control. My experience was documented in this video: Gwen Stritter's Painless Double Mastectomy (see at right).

What if you do get an infection:

• Report symptoms of infection immediately to your surgeon and begin treatment promptly. If antibiotics are prescribed, take as directed.
• Eat well to maintain a healthy nutritional state. Consider consulting a board-certified oncology dietician for specific dietary recommendations.
• If antibiotics are prescribed, eat well and follow other practices to restore a healthy microorganism balance. See Eating Well, Mediterranean Diet and Your Microbiome.
• Consider consulting an integrative oncology specialist about additional measures to clear infection, help wound healing, control inflammation and minimize tissue fibrosis (scarring) from surgical wounds and/or from radiation therapy.

In his book Life over Cancer: The Block Center Program for Integrative Cancer Care, Keith Block, MD, lists glycemia, stress chemistry/biorhythms and inflammation as terrain factors common in breast cancer. Compromised immunity such as from chemotherapy, surgery, anesthesia or opioid use may also increase the risk for infection and recovery. Approaches to address these factors involve healthy lifestyle practices, such as the 7 Healing Practices. You can learn more about Dr. Block’s integrative program to address these terrain factors in his book:

• Chapter 15, Inflammation: Overcoming cancer’s fiery side
• Chapter 16, Immune Surveillance: Mounting the immune barricades
• Chapter 18, Glycemia: Breaking cancer’s sugar addiction

In their books, Lise Alschuler, ND, FABNO, and Karolyn Gazella list five key body pathways to target to make your body inhospitable to cancer. Three of those pathways most relevant to preventing and managing surgical complications are the immune system, insulin resistance and inflammation. See the following chapters:

• The Definitive Guide to Thriving after Cancer: Chapters 1-5
• The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing:
• Chapter 8, Immune system (including stress management)
• Chapter 9, Inflammation
• Chapter 11, Insulin resistance
• Alschuler and Gazella also devote a portion of chapters 6 and 7 to integrative approaches to preparing for, mitigating side effects from and enhancing outcomes of cancer surgery.

The Breast Cancer Companion: A Complementary Care Manual: Third Edition by Barbara MacDonald, ND, FABNO, is an excellent guide for oncology naturopaths caring for those with breast cancer. She provides guidance on natural approaches to consider across the spectrum of breast cancer: reducing inflammation; support through surgery, including wound healing; preventing recurrence and monitoring after conventional treatment is completed. See these sections in particular:

• Chapter 1, section 2.1.4, Inflammation
• Chapter 2, section 2, Diagnostic Tests and Surveillance Tests
• Chapter 4, Preparing for Surgery
• Chapter 9:
  • Section 3, Monitoring while in Remission
  • Section 5, Recurrence Prevention Strategies
  • Section 6, Classical Naturopathic Treatment of Breast Cancer Survivors
  • Section 7, Post-treatment Laboratory Testing

You need to find a balance in monitoring for breast cancer recurrence. Talk with your oncologist about your risk of recurrence and the type and frequency of monitoring best for you. Based on your risk, ask these questions:

• Have we done everything we know to do from a treatment standpoint to treat the breast cancer?
• What type and frequency of monitoring is best for me?
• What are the available monitoring tests and tools?

Valid and reliable tests to pick up on recurrence early are under development. Blood tests such as circulating tumor DNA (ctDNA) and circulating tumor cell testing (CTC) have generated a lot of excitement, but they’re not yet ready for routine clinical use. According to BCCT advisor and breast cancer medical advocate Gwendolyn Stritter, MD, two fairly well-validated ctDNA tests, Guardant 360 and FoundationOne Liquid, are used to monitor treatment response in metastatic breast cancer. She suspects that within the next couple of years these tests may be validated for use in the post-primary/adjuvant, NED (no evidence of disease) setting as a very early warning of impending recurrence. BCCT is monitoring this situation and will update this page when new developments are announced.

Meanwhile, some women with no evidence of disease but at high risk of recurrence have requested ctDNA testing, understanding that insurance is not likely to pay for the tests. Guardant 360 will accept samples only in the case of metastatic breast cancer. Foundation Medicine’s ctDNA test costs about $5800, and—except for metastatic disease—insurance usually won’t cover the costs. Fortunately, Foundation Medicine, and perhaps other companies, do not charge the patient if the test does not reveal any ctDNA. Further, Foundation Medicine and other companies offer financial aid and discount programs in some cases.

For more information on testing see Standard and Non-standard Diagnostic Approaches. Other surveillance tools currently employed with those at increased risk of recurrence are listed on BreastCancer.org’s site: Blood Marker Tests.

Fortunately, this is beginning to change as researchers are steadily showing ways to reduce DCIS treatment while maintaining excellent outcomes. Radiation therapy is a good example. Radiation therapy decreases relapse rates for DCIS, but it does not improve survival. For some patients, the reduction in relapse outweighs other considerations and they opt for radiation therapy. Now with the advent of genomic testing, oncologists are now actively researching tests such as Oncotype DX DCIS⁶⁶⁹ and SweDCIS⁶⁷⁰ that help limit radiation therapy only to those would have a high risk of relapse without it.

Preliminary data also show that even surgery can be avoided in low-risk DCIS. This research is compelling enough that an ongoing 50-state clinical trial of active surveillance vs. surgery in underway: Comparison of Operative to Monitoring and Endocrine Therapy (COMET) Trial For Low Risk DCIS (COMET).

Sentinel lymph node biopsy (SLNB) may also be unnecessary in older women, adding no survival benefit. A large retrospective study of older women diagnosed with DCIS undergoing breast-conserving surgery found no difference in rates of recurrence, occurrence in the other breast or breast cancer mortality among those who did and did not have sentinel lymph node biopsy (SLNB). The researchers concluded that their findings don't support routinely doing SLNB for older patients with DCIS having breast conservation surgery.⁶⁷¹

If you are an older women with DCIS considering breast conserving surgery and your surgeon is suggesting SLNB, you may want to discuss the necessity of having SNLB, weighing the potential for side effects (such as lymphedema) against the benefits. Neither the National Comprehensive Cancer Network nor the American Society for Clinical Oncology recommend SLNB for women with DCIS having breast-conserving surgery.⁶⁷² See also Breast Cancer Treatment in Older Women in More Information below.

It is very exciting to see the breast oncology field moving in the direction where surgery and radiation therapy are used only on the few patients who need them.⁶⁷³

A group in Italy randomized 500 women with non-invasive breast disease to take either 5 mg tamoxifen per day or none at all (placebo group) over the course of three years. They found the decrease in DCIS/LCIS recurrence and that of invasive breast cancer in the low-dose tamoxifen group to be equivalent to what we typically see with the 20 mg dose. They also saw a decrease in new breast cancers/pre-cancers in the other breast. But equally important, the risk of blood clotting and endometrial cancer was indistinguishable from that of the placebo group. Here’s the icing on the cake: the incidence of hot flashes and vaginal symptoms (dryness, pain during sex) was minimally increased over the placebo group.⁶⁷⁴

What’s not to love? Equal effectiveness and decreased side effects! But here are some cautions. This is a relatively small study that followed women to an average of only five years. So this protocol is not quite ready for prime time.

Having said that, here are the situations in which you should consider asking your oncologist about low-dose tamoxifen:

• You have LCIS, ADH or ER+ DCIS, and
• You are at higher risk for endometrial cancer, or
• You are at higher risk for blood clotting, or
• Because of intolerable side effects you plan to stop the tamoxifen 20 mg dose thereby increasing your risk of relapse or invasive breast cancer.

Lifestyle practices are the first steps to get your cardiovascular system in the best shape possible, before treatment if possible but also as part of your survivorship plan for health.

A clinical trial of an exercise intervention in breast cancer patients found good evidence of benefit: "Our findings strongly support that tailored exercise training during adjuvant breast cancer treatment may counteract a decline in cardiovascular function, and in particular among those receiving chemotherapy."⁶⁷⁸

Be sure to consult your doctor before starting an exercise program, particularly if you already have heart or other problems such as neuropathy that may require adjustments to a fitness plan. In this case, a cardiac or cancer rehab program may guide you in choosing safe exercise and movement therapies.

Other foundations for protecting your heart:

• Quit smoking
• Optimize your body weight
• Avoid drugs that stress the heart:
  • Cocaine
  • Diet pills
  • Ephedra/ma huang
  • Performance-enhancing drugs
  • Caffeinated energy drinks⁶⁷⁹

As part of your treatment, you may be given toxic drugs and/or radiation therapy to kill cancer cells. The normal cells in and around your heart can also be killed, resulting in cardiac toxicity. Besides cell death, other types of cardiac toxicity can result from cancer treatment:⁶⁸⁰

• Cardiomyopathy
• Myocarditis
• Pericarditis
• Acute coronary syndromes
• Congestive heart failure

With people living longer after their cancer diagnosis and treatment than in the past, this problem is becoming more prevalent, so much so that a new cancer subspecialty—cardio-oncology—has developed. Many cancer treatment centers have cardio-oncology programs.

From a conventional treatment standpoint, preventing heart problems from cancer treatment involves a baseline test of heart function, monitoring those at risk for problems, and adjusting drug dosage and/or frequency or even changing to a less cardiotoxic drug. Radiation oncology is becoming more and more adept at targeting the cancerous tissue and shielding the heart and lungs. Early treatment of heart problems is more likely to prevent serious damage.

The first step is to get a baseline test of heart function (usually an echocardiogram, or ECG), and repeat this testing during treatment if you are at risk for heart problems.⁶⁸¹ Repeat testing four and 10 years after treatment with doxorubicin.⁶⁸² Survivors of childhood cancer should have an echocardiogram every one to five years ongoing⁶⁸³ and during late-stage pregnancy.⁶⁸⁴

An echocardiogram should be taken periodically during treatment—every three months during treatment with Herceptin/trastuzumab, according to guidelines from the American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging and European Society for Medical Oncology.⁶⁸⁵ An “echo” takes pictures of the heart and measures the strength of the heart/ejection fraction. Ejection fraction over 55 percent is normal, a mildly weak heart is at 45 to 55 percent, a moderately weak heart is 30 to 45 percent, and below 30 percent is considered severely weakened.

Milk thistle: In a controlled trial, cancer survivors who took milk thistle during doxorubicin treatment had better heart function compared to placebo. Study authors concluded that silymarin "can be recommended as adjuvant drug in patients with ALL under doxorubicin therapy."⁶⁸⁶ Silymarin, a main component of milk thistle, protected animal heart and liver tissue against doxorubicin-induced toxicity.⁶⁸⁷ An earlier trial showed that milk thistle is safe to combine with chemotherapy.⁶⁸⁸ See a commentary about use of milk thistle during chemotherapy treatment on our Milk Thistle summary.

Coenzyme Q10 (CoQ10): In a controlled trial, CoQ10 use with doxorubicin preserved heart function.⁶⁸⁹ In another small controlled trial in Japan, CoQ10 use during doxorubicin and radiation treatment preserved heart function.⁶⁹⁰ Researchers hypothesize that CoQ10 prevents doxorubicin from binding to heart muscle cells.⁶⁹¹ Animal studies also show that CoQ10 supplementation improves the functional and structural integrity of the myocardium during doxorubicin treatment.⁶⁹²

Before taking coQ10, consult with your doctor. Because CoQ10 is an antioxidant, it may theoretically interfere with some chemotherapy drugs (such as anthracyclines and cyclophosphamide) or radiation therapy. “Recent in-vitro [cell] studies, however, have shown that CoQ10 does not affect the antineoplastic properties of doxorubicin.”⁶⁹³

L-carnitine (About Herbs): Many people who have low carnitine from chemotherapy will have weakness in large muscle groups, which can make your legs feel like jello when you walk up the stairs. L-carnitine is established as improving heart function following a heart attack. In a meta-analysis, use of L-carnitine after heart attack was associated with a 27 percent lower risk of dying and 65 percent lower risk of irregular heart rate.⁶⁹⁴ In a randomized controlled trial of cancer patients, L-carnitine during doxorubicin treatment improved signs of heart muscle toxicity.⁶⁹⁵ Young cancer survivors who received doxorubicin have lower plasma carnitine levels than controls, so L-carnitine has been suggested as a way to prevent heart damage.⁶⁹⁶ Many people who have low carnitine from chemotherapy will have weakness in large muscle groups, which can make your legs feel like jello when you walk up the stairs. Animal studies also show that L-carnitine supplementation improves the functional and structural integrity of the myocardium during doxorubicin treatment.⁶⁹⁷

Ginkgo (About Herbs): In a controlled trial in China, people who took Gingold during doxorubicin treatment had fewer abnormal echocardiograms compared to doxorubicin alone.⁶⁹⁸ Because ginkgo does not affect how most medicines are metabolized, it appears to be safe to combine with chemotherapy,⁶⁹⁹ tamoxifen, anastrozole or letrozole.⁷⁰⁰ Ginkgo added to aspirin (either 325 mg⁷⁰¹ or 500 mg⁷⁰² did not affect bleeding risk.

Arginine (About Herbs): In a controlled trial, people who took arginine along with doxorubicin had less shortness of breath, palpitations, and fewer ECG changes.⁷⁰³

Iodine: In a randomized pilot study, women who took iodine during epirubicin chemotherapy for breast cancer had significantly lower levels of heart distress enzymes (creatine kinase-MB) than those taking a placebo.⁷⁰⁴

Hawthorn berry/crataegus (About Herbs): In a meta-analysis, hawthorne berry improved heart strength/ejection fraction and symptoms of congestive heart failure.⁷⁰⁵

L-carnitine (About Herbs): In a meta-analysis, L-carnitine improved heart strength/ejection fraction and symptoms of congestive heart failure.⁷⁰⁶

Taurine (About Herbs): In double-blind, randomized, controlled trials, taurine improved heart function and signs of congestive heart failure.⁷⁰⁷

Combination of taurine, CoQ10 and L-carnitine: In a double blind randomized controlled trial, patients who took 3 g taurine, 3 g carnitine and 150 mg CoQ10 had better heart function.⁷⁰⁸

Astragalus: In a randomized controlled trial, astragalus improved heart strength/ejection fraction.⁷⁰⁹

Berberine (WebMD): In a randomized controlled trial, berberine improved heart strength/ejection fraction, ability to exercise, symptoms of congestive heart failure, and heartbeat regularity/ventricular premature complexes.⁷¹⁰ Dr. Barbara MacDonald recommends against taking berberine during taxol treatment.⁷¹¹

Magnesium (About Herbs): In a double blind randomized controlled trial, people with severe congestive heart failure who took magnesium had better symptoms and survival.⁷¹²

A heart-support protocol developed by Michael Walker, ND, FABNO, includes magnesium (About Herbs), CoQ10, L-carnitine (About Herbs), fish oil, and exercise that can improve heart function that drops during treatment with Herceptin/trastuzumab or Perjeta/pertuzumab.

Because such a complex system is difficult to study, researchers turned away from looking at just CYP2D6 and are focusing on the endoxifen level itself (ignoring the middleman). In one study, researchers in the Netherlands gave tamoxifen with or without curcumin 1200 mg three times a day. The group taking tamoxifen in combination with curcumin had about an 8 percent decrease in endoxifen levels. If the curcumin was compounded with piperine (often done to substantially improve curcumin absorption), endoxifen levels were further decreased by 12 percent.⁷¹⁵

Although an 8 to 12 percent reduction doesn’t seem like much, if your genetics and/or dietary habits result in levels of endoxifen just barely in the effective range, the addition of curcumin, and especially with piperidine, could tip the scales in favor of breast cancer growth. The authors of this paper conclude: “co-treatment with curcumin could lower endoxifen concentrations below the threshold for efficacy (potentially 20 to 40 percent of the patients).”

Do keep in mind that this was a very small study, only 16 patients. However, these results are in line with previous lab and animal research so should not be discounted. On the other hand, curcumin supplementation has documented beneficial effects: decreased depression,⁷¹⁶ anti-inflammatory effects⁷¹⁷ and lowered cholesterol,⁷¹⁸ to name a few.

The bottom line: if you are taking curcumin with tamoxifen, ask your integrative practitioner if s/he could substitute another supplement. If not, then request to have your endoxifen levels checked, both before and a month after starting curcumin. Quest Diagnostics, a very reputable lab, offers a “tamoxifen and metabolites” blood test.

Some blends that I often recommend:

Per capsule:

• Trametes versicolor (turkey tail) (40% polysaccharides, 40% beta-glucans) - 100mg
• Grifola frondosa (maitake) 40% polysaccharides, 30% beta-glucans - 100mg
• Ganoderma lucidum (reishi), 40% polysaccharides, 15% beta-glucans - 100mg
• Lentinula edodes (shiitake), 409% polysaccharides, 40% beta-glucans - 100mg

I would recommend between 2-3 capsules twice daily.

When recommending single mushrooms, it is important to know how much beta-glucan is in each serving so that I can titrate my dose accordingly. For instance, I often use Grifola frondosa (maitake) mushroom to increase white blood cell counts. One product I use contains:

Per 6 tablets:

• Maitake (Grifola frondosa) Fruiting body powder - 600mg
• Maitake fruiting body extract, standardized to contain 30% D-fraction - 240mg (so 72mg D-fraction beta glucan)
• Vitamin C 120mg (supports bioactivity)

Costs permitting, in most clinical studies, the daily dose of mushroom extracts that is correlated with improved survival (especially in breast, colorectal, gastric cancers) is 3000mg/day.

Mushrooms do pack a punch! From a meta-analysis on Coriolus versicolor mushroom extracts in patients diagnosed with cancer:⁷¹⁹

• Over all cancers, there was a 9 percent absolute reduction in 5-year mortality (one additional patient alive for every 11 patients treated).
• Effects were more evident for breast, gastric or colorectal cancer versus esophageal or nasopharyngeal.