Cancer patients should not hesitate to speak with their doctors about dietary supplements

Many cancer patients use dietary supplements such as vitamins, minerals and herbs or other botanicals but often don’t tell their doctor.

This gap in communication can happen when patients believe that their doctors are indifferent or negative toward their use of these supplements. As a result, patients may find information about dietary supplements from unreliable sources, exposing themselves to unneeded risks. Since information on these dietary supplements is limited, researchers from the University of Texas Medical Branch describe a practical patient-centered approach to managing dietary supplement use in cancer care in a review article. Improving the communication between patient and doctor in this area is critical. The article was published in the September edition of Current Oncology Reports.

Globally, people spent an estimated $96 billion on dietary supplements in 2012 and the National Institutes of Health devoted $855 million during fiscal years 2009-2011 to research on this topic. Despite ongoing research, little is known about the effectiveness of dietary supplements in cancer care. Regardless, many studies have confirmed that most patients undergoing cancer therapy use self-selected forms of complimentary and integrative medicine such as dietary supplements.

Doctors need to understand why patients with cancer use dietary supplements in the first place. Patients tend to use these supplements because they want to do everything possible to feel hopeful, empower themselves, enhance the body’s natural defenses, use less toxic treatments, or reduce side effects of mainstream treatments,” said Dr. Victor Sierpina, UTMB professor of family medicine. “In fact, most patients choose to use dietary supplements to improve their quality of life rather than seeking a cure for their disease.”

When doctors fail to communicate effectively with patients who are using dietary supplements, they may lose the patient’s trust and the patient may gather information from a variety of places, such as advice from friends and relatives or the Internet. At times this information is not correct and occasionally can be dangerous.

Dr. Sierpina and fellow author Dr. Moshe Frenkel, UTMB clinical associate professor of family medicine, emphasize that doctor-patient communication is an interactive process, not merely a focused dialogue of questions and answers. The doctor who is open to patient inquiries and is aware of subtle, nonverbal messages can create an environment of safety in which a patient feels and is protected.

Doctors must use a sensitive approach when communicating with a patient who has an interest in the use of dietary supplements,” said Dr. Frenkel. “A communication approach that fosters a collaborative relationship that includes ample information exchange, empathy and compassion, responding to emotional needs and managing uncertainty can lead to informed decisions about dietary supplement use.”

This discussion is crucial in building a personalized treatment plan that is safe and based on reliable information. This article contains a list of the most common dietary supplements and basic information related to these as well as a table containing reliable sources of information on dietary supplements for both doctors and patients, for further reference.

Frenkel M and Sierpina V (2014). The Use of Dietary Supplements in Oncology, Cur. Oncol. Rep.,  16:411 [Abstract]

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Scientists engineer toxin-secreting stem cells to treat brain tumors

Proof-of-concept study highlights new therapeutic use of engineered human stem cells

Harvard Stem Cell Institute scientists at Massachusetts General Hospital have devised a new way to use stem cells in the fight against brain cancer. A team led by neuroscientist Khalid Shah, MS, PhD, who recently demonstrated the value of stem cells loaded with cancer-killing herpes viruses, now has a way to genetically engineer stem cells so that they can produce and secrete tumor-killing toxins.

In the journal Stem Cells, Shah’s team shows how the toxin-secreting stem cells can be used to eradicate cancer cells remaining in mouse brains after their main tumor has been removed. The stem cells are placed at the site encapsulated in a biodegradable gel. This method solves the delivery issue that probably led to the failure of recent clinical trials aimed at delivering purified cancer-killing toxins into patients’ brains. Shah and his team are currently pursuing FDA approval to bring this and other stem cell approaches developed by them to clinical trials.

Cancer-killing toxins have been used with great success in a variety of blood cancers, but they don’t work as well in solid tumors because the cancers aren’t as accessible and the toxins have a short half-life,” said Shah, who directs the Molecular Neurotherapy and Imaging Lab at Massachusetts General Hospital and Harvard Medical School.

A few years ago we recognized that stem cells could be used to continuously deliver these therapeutic toxins to tumors in the brain, but first we needed to genetically engineer stem cells that could resist being killed themselves by the toxins,” he said. “Now, we have toxin-resistant stem cells that can make and release cancer-killing drugs.”

Cytotoxins are deadly to all cells, but since the late 1990s, researchers have been able to tag toxins in such a way that they only enter cancer cells with specific surface molecules; making it possible to get a toxin into a cancer cell without posing a risk to normal cells. Once inside of a cell, the toxin disrupts the cell’s ability to make proteins and, within days, the cell starts to die.

Shah’s stem cells escape this fate because they are made with a mutation that doesn’t allow the toxin to act inside the cell. The toxin-resistant stem cells also have an extra bit of genetic code that allows them to make and secrete the toxins. Any cancer cells that these toxins encounter do not have this natural defense and therefore die. Shah and his team induced toxin resistance in human neural stem cells and subsequently engineered them to produce targeted toxins.

We tested these stem cells in a clinically relevant mouse model of brain cancer, where you resect the tumors and then implant the stem cells encapsulated in a gel into the resection cavity,” Shah said. “After doing all of the molecular analysis and imaging to track the inhibition of protein synthesis within brain tumors, we do see the toxins kill the cancer cells and eventually prolonging the survival in animal models of resected brain tumors.”

Shah next plans to rationally combine the toxin-secreting stem cells with a number of different therapeutic stem cells developed by his team to further enhance their positive results in mouse models of glioblastoma, the most common brain tumor in human adults. Shah predicts that he will bring these therapies into clinical trials within the next five years.

Stuckey et al., (2014). Engineering toxin-resistant therapeutic stem cells to treat brain tumors. Stem Cells, DOI: 10.1002/stem.1874 [Abstract]

Study measures breast cancer tumor response to neoadjuvant chemotherapy

DOST imaging could be used to predict tumor response before starting treatment

A Dartmouth study suggests that it may be possible to use Diffuse Optical Spectroscopic Tomographic imaging (DOST) to predict which patients will best respond to chemotherapy used to shrink breast cancer tumors before surgery. These findings could eliminate delays in effective early treatment for tumors unlikely to respond to neoadjuvant chemotherapy (NAC). The study, “Predicting breast tumor response to neoadjuvant chemotherapy with Diffuse Optical Spectroscopic Tomography prior to treatment,” was published online in Clinical Cancer Research.

Breast cancer is the most common non-skin cancer in women worldwide, and the second leading cause of women’s cancer mortality in the United States. A common treatment strategy after diagnosis is to shrink breast cancer tumors larger than 3 centimeters with a 6- to 8-month course of NAC prior to surgery. Clinical studies have shown that patients who respond to NAC have longer disease-free survival rates, but only 20 to 30 percent of patients who receive NAC fit this profile.

Our work represents the first clinical evidence that tumor total hemoglobin (estimated from DOST images) is different in the women with locally advanced breast cancer who respond to neoadjuvant chemotherapy,” said lead author Shudong Jiang, associate professor of Engineering at the Thayer School of Engineering at Dartmouth. “We were able to predict breast tumor response to NAC based on image data acquired before the initiation of therapy.”

DOST imaging is used to measure tumor tissue for hemoglobin and oxygen saturation levels—key indicators of the presence the tiny blood vessels cancer tumors need to grow. This study suggests that biomarkers obtained through DOST imaging could help physicians determine the best treatment strategy for patients.

The implication of this information is that certain tumors are pre-disposed to responding to neoadjuvant chemotherapy, and that this predisposition could be known prior to choosing the therapy,” says Jiang. “The study also could dramatically accelerate future randomized clinical trials on optimal NAC regimes. By using a validated imaging surrogate as an outcome measure, we could potentially reduce the number of patients required, and the length of time they need to be followed.”

Jiang says the next step will be to develop a portable and compact system to more accurately measure changes in the breast prior or/and during neoadjuvant chemotherapy. This system could be integrated into the workflow of clinical oncology practice to maximize patient participation, and determine whether additional prognostic information could be obtained that would influence patient management.

Jiang et al., (2014). Predicting breast tumor response to neoadjuvant chemotherapy with Diffuse Optical Spectroscopic Tomography prior to treatment. Clin. Cancer Res., EPub Ahead of Print, doi:10.1158/1078-0432.CCR-14-1415 [Abstract]

Antineoplastic drugs often not handled within safety guidelines

A new National Institute for Occupational Safety and Health (NIOSH) study, published online in the Journal of Occupational and Environmental Hygiene, found that recommended safe handling practices for workers who administer antineoplastic drugs in healthcare settings are not always followed.

Results are derived from the 2011 Health and Safety Practices Survey of Healthcare Workers, the largest federally-sponsored survey of healthcare workers in the U.S., which addresses safety and health practices relative to use of hazardous chemicals. This paper presents findings on current administrative and engineering control practices, personal protective equipment (PPE), and barriers to using recommended PPE during administration of antineoplastic drugs by nearly 2,100 oncology nurses and other healthcare personnel who completed a module addressing antineoplastic drug administration.

Chemotherapy drugs save lives of cancer patients but also can result in adverse health outcomes in workers who are exposed to these drugs, including cancer, reproductive problems, and organ damage when recommended safe handling guidelines are not followed,” said NIOSH Director John Howard, MD. “Safeguarding healthcare workers from potential occupational hazards is an essential part of providing good jobs for these dedicated women and men, and furthering high-quality patient care.”

Findings suggest that best practices are not always used. Below are examples of practices that may increase exposure risk, expressed as percent of respondents:

    • Not always wearing two pairs of chemotherapy gloves (80%) or not even a single pair (15%).
    • Failure to always wear nonabsorbent gown with closed front and tight-fitting cuffs (42%).
    • Intravenous (I.V.) tubing primed with antineoplastic drug instead of a non-drug containing liquid by the respondent (6%) or by the pharmacy department (12%).
    • Potentially contaminated clothing taken home (12%).
    • Spill or leak of antineoplastic drug during administration (12%).
    • Lack of hazard awareness training (4%)
    • Skin contact with antineoplastic drug (4%).

Despite the longstanding availability of authoritative safe handling guidelines (ASHPNIOSH ONSOSHA), recommended exposure controls were not always used. According to NIOSH, this is highly noteworthy considering that there is no safe level of exposure to cancer-causing agents. Reported barriers to using PPE suggest that there is a perception that exposures are inconsequential or so rare that employers or workers feel PPE use is not justified.

The researchers conclude that better risk communication is needed to ensure that employers and employees are fully aware of the hazards and the availability of precautionary measures to minimize exposures. Commitment from all levels in the healthcare organization is essential to adequately protect workers from one of the most toxic classes of chemical agents used in healthcare.

NIOSH is the federal agency that conducts research and makes recommendations for preventing work-related injuries, illnesses and deaths. The findings from this survey are expected to help NIOSH, partners, employers, and healthcare workers better understand current health and safety practices relative to working with hazardous chemical agents, identify gaps in current knowledge about those practices, and, in collaboration with partners, design further research for addressing those gaps.

Boiano et al., (2014). Adherence to Safe Handling Guidelines by Health Care Workers Who Administer Antineoplastic Drugs. J. Occup. Environ. Hyg., 11: 728-740, DOI:10.1080/15459624.2014.916809 [Abstract]

Osteoporosis treatment may also benefit breast cancer patients

Treatment approaches to reduce the risk of bone complications (metastasis) associated with breast cancer may be one step closer to becoming a reality. 

According to a study led by a team at the Research Institute of the McGill University Health Centre (RI-MUHC), findings show that medication used to treat bone deterioration in post-menopausal women may also slow skeletal metastasis caused from breast cancer. This study, published in this month’s issue of the Journal of the National Cancer Institute (JNCI), is among the first to link bisphosphonate (a common osteoporosis medication) use with improved survival in women with breast cancer.

Skeletal metastases develop in up to 70 percent of women who die from breast cancer,” says study co-lead author, Dr. Richard Kremer, director of the Bone and Mineral Unit at the MUHC and a professor in the Faculty of Medicine at McGill University. “This causes considerable suffering and is life-threatening. Preventing this could translate into saving a significant number of lives.”

Dr. Kremer and co-lead author, Dr. Nancy Mayo, worked with colleagues to evaluate data from more than 21,000 women diagnosed with breast cancer. The relationship between use of oral bisphosphonates and development of bone metastases after diagnosis with breast cancer was evaluated in two groups of women: those with early stage, localized, cancer and those whose cancer had spread to lymph nodes. Their findings showed that women with early stage breast cancer who had taken oral bisphosphonates, either before or after diagnosis of their cancer, had a reduced risk of bone metastasis. In addition, their study showed that women with later stage cancer, who took oral bisphosphonates post-diagnosis, also had a significantly reduced risk of bone metastasis.

The researchers also established a dose-response relationship with oral bisphophonate use in women with local disease: longer time spent on bisphophonate medication resulted in a greater reduction of bone metastases.

Our study is novel in that it mainly involved women who were post-menopausal and in whom bone-turnover is high due to osteoporosis,” says Dr. Richard Kremer who is also an RI-MUHC researcher. “We believe that this process results in an environment that is favorable for tumour cell growth and consequent metastasis. We know that bisphosphonates work by slowing down this bone-turnover. This will, in turn, make it harder for tumour cells to establish in the bone and may explain why we saw such a decline in metastasis.”

An association between bisphophonate use and improved survival was also observed and this merits further investigation,” Dr. Mayo, RI-MUHC researcher and James McGill professor in the Faculty of Medicine, School of Physical and Occupational Therapy at McGill. “Ours was an epidemiological study, involving a large number of women strengthening the importance of the findings. However, clinical interventional studies are needed before the results can be translated into standard clinical practice and guidelines.”

Kremer et al., (2014). Effect of Oral Bisphosphonates for Osteoporosis on Development of Skeletal Metastases in Women With Breast Cancer: Results From a Pharmaco-epidemiological Study. J. Natl. Cancer Inst., 106 (11): dju264 doi: 10.1093/jnci/dju264 [Abstract]