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Cancer, lifestyle and chemotherapy

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Cancer is an illness which has an enormous impact upon the well being of patients, their families, the health care system, and the wider community. Managing cancer requires a multi-disciplinary and holistic approach utilizing evidence-based medical and surgical treatments, lifestyle advice and complementary therapies. This approach is best described as Integrative Medicine. The Gawler Foundation and its members are committed to working within the context of Integrative Medicine. This approach aims to foster the best outcomes for cancer patients, families and the community through informed decision making and the provision of quality skills, resources and information.
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Discussion paper

Cancer, lifestyle and chemotherapy

Dr Ian Gawler OAM BVsc MCouns&HS
Founder and Therapeutic Director, The Gawler Foundation, Yarra Junction, Victoria

Prepared with assistance from other staff, particularly Dr Craig Hassed MBBS FRACGP
Senior Lecturer, Department of General Practice, Monash University, Victoria

June 2007


Cancer in context
Cancer is an illness which has an enormous impact upon the wellbeing of patients, their
families, the healthcare system, and the wider community. Managing cancer requires a
multi-disciplinary and holistic approach utilising evidence-based medical and surgical
treatments, lifestyle advice and complementary therapies. This approach is best
described as Integrative Medicine. The Gawler Foundation and its members are
committed to working within the context of Integrative Medicine. This approach aims to
foster the best outcomes for cancer patients, families and the community through
informed decision making and the provision of quality skills, resources and information.

As difficult a problem as cancer is for patients and clinicians alike, the recent Senate
inquiry into the management of cancer in Australia suggested that there is much room
for improvement. Some of the main recommendations included:
Setting up and funding existing multidisciplinary cancer centres integrating
holistic and Complementary Medicine (CM)
Recognising the need for patients to be informed about CM
NHMRC dedicating funding, personnel and support to CM cancer research
Making quality information more available to assist patients in making informed
decisions about cancer management
That Cancer Australia examine funding mechanisms for programs and activities
like those operated by The Gawler Foundation and give consideration from a
health and equity point of view of providing Medicare deductibility for cancer
patients accessing these services.

Incidence
Around 88,000 people are diagnosed with cancer annually.1 At any one time, about
267,000 people are living with cancer in Australia.2

This means that for every 100,000 people in the community, about 1,250 are living with
a diagnosis of cancer, and about 440 new cases will be diagnosed annually.
Currently about 56% of all people diagnosed with cancer are cured of their disease.3 By
gender, 60% of women and 52% of men are cured. This means that 44%, or around
38,720 people are diagnosed annually with a potentially incurable cancer.


There are about 32,000 GPs in Australia.4 On average therefore, each GP will diagnose
around three new people with cancer annually and have around eight people living with
cancer amongst their patient list.

Definitions
To facilitate effective communication, it is important that definitions are clear and used
consistently. Everyone needs to be aware that many in the public and media, and even
some in the medical system are using definitions in cancer medicine loosely and that this
may lead to misunderstandings amongst the public regarding the potential benefits and
risks of treatment options.

Curative treatment
Curative treatment aims to render the person clinically free of detectable cancer and
restore the person to their normal life expectancy.5

Palliative care
Palliative care is an umbrella term for assisting those approaching death - a fundamental
need and right. It is generally used in the context that death is imminent and inevitable
and aims to make dying as easy and comfortable as possible.

Palliative treatment
Palliative treatment is a specific but integral part of palliative care. Palliative treatment
can be more interventionist. It is non-curative by definition but aims to extend life,
ameliorate symptoms and increase quality of life in situations where cure is not medically
feasible.

Prognosis and statistics
When it comes to evaluating the benefits of any treatment, whether curative or palliative,
it is important to understand the difference between relative or absolute benefits. For
example, a treatment that reduces a risk of dying from 4% to 2% may be expressed as a
relative reduction in risk of 50%, as it halves the risk of dying and sounds good, or, an
absolute reduction in risk of 2%, as it reduces the risk of dying by 2% which does not
sound like much.

Prognosis is best assessed using statistics rather than making a statement such as “you
have 3 months to live”. A method for this is to answer the following questions.6

Q1. If 100 people had no treatment
How many would be alive after 1 year and what would their health be like?
How many would be alive after 5 years and what would their health be like?

Q2. If 100 people had this treatment
How many would be alive after 1 year and what would their health be like?
How many would be alive after 5 years and what would their health be like?

Q3. If 100 people had this treatment
What side effects are possible and how many people would have them?

Q4. What impact will my own responses have?
What can I do to help myself?


2



What will my state of mind be like?
-
fear and loathing, or gratefully embracing
-
how committed will I be to this treatment?
What are my support systems like?
-
personal
-
external

Once these questions are answered (with the best quality information available) then the
equation of pluses and minuses can be discussed, balanced, considered, contemplated
and an informed decision made.

The bell curve
The bell curve helps patients to understand so called “normal distributions” and to
consider what factors may influence where a given individual may end up on the curve.
For example, a good diet and regular exercise is highly likely to affect a shift to the right.


No. of
Deaths

Time


Survival
Survival refers to how long a person lives with a particular condition (e.g., they survived
6 months or 6 years). This is different to cure which implies surviving the cancer and
dying of something else; but in fact means returning to a normal life expectancy. A
person does only know for sure that they are cured of cancer when they die of
something else.

Response
A response to treatment could refer to any response. However, in cancer medicine it
usually implies reduction in the sise of a tumour. Doctors need to be aware that
“response” is often mistaken by patients as a “cure”.

Integrative Medicine
The term Integrative Medicine refers to a style of medical practice which is holistic and
integrates the best and safest of conventional medical care with lifestyle advice and
evidence-based complementary medicines and/or therapies. It aims to use the most
appropriate of all available modalities and to help each individual patient make informed
choices.



3



Orthodox or Conventional Medicine
Orthodox or conventional medicine generally describes medical interventions that are
taught at medical schools, generally provided at hospitals, and meet the requirement of
peer accepted mainstream medicine and standards of care.

Complementary Medicine
Complementary medicine refers to a medicine or therapy that is used in addition to, or
complements conventional medicine. Complementary medicine is increasingly taught in
medical schools and practiced in hospitals and is steadily gaining widespread support.
More research is needed, to better evaluate it.

Lifestyle Factors
Lifestyle factors are concerned with what a person can do for themselves in the context
of their daily life. They are diverse, have a major impact upon health, and include
physical, psychological, social and spiritual factors including diet, exercise, stress
management, social support, leisure or work. Although they warrant being a core
element in conventional medical care, many patients perceive, rightly or wrongly, that
doctors do not take sufficient time or interest in lifestyle factors, hence, it is one of the
main reasons for patients attending CM practitioners. Although cancer patients often
seek help with lifestyle factors from complementary therapists and self-help programs as
a part of their treatment, lifestyle factors benefit from being distinguished from
complementary therapies for a range of reasons.
a. They have a stronger evidence-base supporting their use.
b. Their safety is high and has been more clearly defined.
c. The ‘side-effects’ of appropriate lifestyle change tend to be beneficial.
d. They should be seen as integral to conventional medical care rather than
being a secondary option.

Complementary medicine and usage
The use of natural, complementary and alternative medicines and therapies in Australia
is considerable and increasing. Complementary medicine generally involves a person
seeking help from a practitioner and/or the taking of medications and/or utilising
products.

It has been estimated from a South Australian survey that in 2000 approximately 52% of
the Australian population used complementary medicines and that 23% consulted
practitioners of complementary medicine. This represents an estimated out of pocket
spending of $2.3 billion which is a 62% increase since 1993 and four times the out of
pocket spending on pharmaceutical drugs.7 Also, in 2000, 23% had consulted at least
one alternative non-medical practitioner in the South Australian survey.8

Among cancer patients, it is estimated that 7-64% of adults use CM.9 Figures vary with
country, time and definition of CM. 31-87% of paediatric cancer patients use CM as a
result of parental choice.10

Complementary and alternative medicine, as defined by the National Center for
Complementary and Alternative Medicine (NCCAM) is a group of diverse medical and
health care systems, practices, and products that are not presently considered to be part
of conventional medicine.11



4



NCCAM classifies natural, complementary and alternative medicines into five categories,
or domains:

Alternative medical systems
Alternative medical systems are built upon complete systems of theory and practice such
as homeopathic and naturopathic medicine, traditional Chinese medicine and Ayurveda.

Mind-body interventions
These interventions include patient support groups, cognitive-behavioural therapy,
meditation, prayer, spiritual healing, and therapies that use creative outlets such as art,
music, or dance.

Biologically based therapies
These therapies include the use of herbs, foods, vitamins, minerals and dietary
supplements.

Manipulative and body-based methods
These methods include chiropractic or osteopathic manipulation, and massage.

Energy therapies
These therapies involve the use of energy fields. They are of two types:
a. biofield therapies such as qigong, reiki, and therapeutic touch
b. bioenergetic therapies involving the use of pulsed electromagnetic fields, such
as pulsed fields, magnetic fields, or alternating-current and/or alternating and
direct-current fields.

Differentiating between complementary medicine and lifestyle factors
By contrast, lifestyle factors are concerned with what a person can do for themselves in
the context of daily life. The Gawler Foundation focuses upon lifestyle factors; providing
professionally led psycho oncology groups that are based upon health education (e.g.,
what to eat, how to meditate, mindfulness) and which include a range of
psychotherapeutic interventions (e.g., cognitive behavioural therapy).

Life factors include:

Physical interventions
Nutrition - food
Exercise
Sunlight
Hobbies

Mind-body interventions
Group therapy - support, self help, etc
The power of the mind - positive thinking, etc
Meditation
Yoga, qigong, tai chi, etc
Creative activities - art, music, dance, gardening
Emotional health - relationships, sexuality
Personal development and transformation



5



Spiritual pursuits
Exploring meaning and purpose
Prayer
Spiritual healing
Religious practice
Spiritual development

Although there is growing evidence that a number of CAMs can be safe and helpful in
cancer management, particularly in the area of symptom control, there are a number of
legitimate concerns regarding the use of CAM among cancer patients.

These concerns include:
Heightened concerns for vulnerable cancer patients and families
The suggestion of false hope
The potential for monetary exploitation
Delayed use of effective conventional treatments
Little scientific evidence for some therapies
Potential dangers, interactions and side-effects
Poor training and regulation of some practitioners.

Of course, these issues are just as relevant for the conventional cancer care as they are
for complimentary therapies and lifestyle factors.

Chemotherapy

Chemotherapy and its efficacy

Chemotherapy is associated with significant cure rates for 50% or more of childhood
cancers, 50% or more of Hodgkin Lymphoma and certain aggressive lymphomas, 75%
or more of carcinoma of the testes, 90% of choriocarcinoma in woman, 15 to 20% of
adult acute leukemia, and 15 to 20% of ovarian carcinoma.

Chemotherapy provides substantial improvement in survival times, but is rarely curative,
for a number of cancers, including carcinoma of the breast and osteogenic sarcoma.
Chemotherapy may substantially palliate symptoms in some cancers, even though
survival benefits are unknown or negligible, including carcinoma of the prostate. It may
occasionally produce responses and modest survival benefits at the expense of
moderate to severe toxicity, including brain cancers and malignant melanoma.12

In 2004, a meticulous analysis of the published data by Morgan of 22 types of cancer in
adults, including breast, prostate, bowel & lung found that the overall benefit of
chemotherapy to 5 year survival was a mere 2.3% in Australia.13

Morgan stated that “the minimal impact on survival in the more common cancers conflicts
with the perceptions of many people who feel they are receiving a treatment that will
significantly enhance their chances of cure”.

According to Segelov (2006), the aim of the great majority of chemotherapy is palliative,
not curative.14 This being so, the question then is what is the most effective form of
palliation and in individual cases, do the side effects of chemotherapy warrant its use in
palliative treatment?


6



Chemotherapy and side effects
The Adverse Drug Reaction Advisory Committee (ADRAC) collects reports of suspected
adverse drug reactions. Chemotherapy reactions are so common that they are generally
considered normal and not regularly reported.

However, despite this, for the platinum group of chemotherapy agents, ADRAC has listed
346 different and specific reactions ranging from nausea to cardiac arrest to depression,
and 65 incidents of deaths.15

Sir Charles Gairdner Hospital, Perth, sees 50,000 patients per annum. For the period
July to December 2005, it saw 68 patients with sepsis (acute infections) following
chemotherapy. All required hospitalisation.16

Chemotherapy and its acceptance
People with advanced cancer are more willing to accept chemotherapy with a lower
chance and a shorter duration of benefit than others imagine. Health professionals must
recognise this when discussing treatment options with patients.17

Duric et al in 2006 researched women with early breast cancer who had received
chemotherapy at least 3 months prior.18 They were asked if they were given another
round of chemotherapy and it were to add just one more day to an imagined 5 year
survival without chemotherapy, would they have it? Over 50% said yes.

Chemotherapy and breast cancer - a specific example
In 1998, out of 10,661 women who were diagnosed with breast cancer, 4,638 were
considered eligible for chemotherapy. From this group only 164 gained some survival
benefit, i.e., chemotherapy increased 5 year survival in early breast cancer by 3.5%.19

Whilst newer chemotherapy regimes (inc taxanes & anthracyclines) may increase
survival by 1% at the expense of the risk of cardiac toxicity & nerve damage, to date
there is no convincing evidence that newer and more expensive regimes are more
beneficial.20 Morgan et al conducted two systematic reviews that have shown no survival
benefits for chemotherapy in secondary breast cancer.

Chemotherapy summary
Tables 1 and 2 summarise the benefits of chemotherapy.
Table 1. Chemotherapy in general
Is curative for a good percentage of childhood cancers and some of the less
common adult cancers.
Taken overall, for most common cancers, improves 5 year survival rates by
2.3%.
Generally speaking, can be regarded as palliative.
Does have considerable cost in side effects and financial terms.



7




Table 2. Chemotherapy for breast cancer
Improves survival in early stages by 3.5%.
Has no evidence for survival benefits for secondary breast cancer.
Has considerable costs in side effects and financial terms.

Lifestyle factors
Lifestyle factors have the potential to assist people diagnosed with cancer during every
phase of the disease. Just as with heart disease and diabetes, Lifestyle Factors relate
directly to the cause and prevention of cancer, provide real support for anyone
diagnosed with the disease and may well improve outcomes significantly.

Lifestyle as a cause of cancer
Cancer is essentially a lifestyle disease, with around 80% of the recognised causes being
lifestyle related and about 10% related to inherited, genetic factors.21 People need to be
aware that recent research identifies lack of sunlight as a major risk factor for cancer. For
example, 25% of breast cancers in Europe are now linked to lack of sunlight.22 The
strongest relationship between lack of sunlight and cancer is for breast, colon & ovarian
cancers. Other cancers identified as being affected are: bladder, uterus, oesophagus,
rectum & stomach.

Lifestyle and cancer prevention
People need to be aware that the best way to treat cancer is to prevent it! The best
prevention is a healthy lifestyle. There is a good body of evidence to support this
proposition, the detail of which is outside the scope of this paper.

Lifestyle factors and efficacy
Do lifestyle factors reduce recurrence rates and mortality? No solid evidence to date has
been produced that proves that a change in lifestyle cures cancer. Only a little definitive
research in this area exists which is of great interest. What research there is points to a
distinct possibility of significant gains but more specific trials are needed urgently.

Research on lifestyle factors and cancer
Considerable research has been undertaken exploring the impact of a number of lifestyle
factors on people with cancer.

The Ornish Prostate Study
One randomised controlled trial to date is the Ornish Prostate cancer study.23 Men in the
watchful waiting group of the Ornish study utilised group support, meditation, low fat,
vegetarian diet, stress management, and yoga.

Results proved a 4% reduction in PSA levels whilst the control group had a 6% increase
in PSA levels, a difference of 10% between groups. Further, by contrast to the control
group, no men in the intervention group went on to require major medical treatment
which in prostate cancer is commonly quite invasive. However, more time is needed to
observe if these early benefits are sustained. Therefore it is too early to claim this as a
potential cure, but these results are encouraging. This trial needs replicating - both in
prostate cancer and other cancers.



8



There exists a good body of supportive evidence in the literature for the therapeutic
benefits of lifestyle interventions, with a specific focus on breast cancer (where most of
this type of research has been carried out).

Vegetable intake
\A study by Rock et al on women with breast cancer found that long term high level
vegetable intake (as measured by plasma carotenoids) reduced the risk of recurrence by
40%.24 This study supports previous findings.

Exercise
A study by Holmes et al25 found that three to nine hours of exercise per week halved the
risk of dying in women with breast cancer, whilst nine hours or more per week reduced
absolute mortality risk by 6% at 10 years. Hayden et al found that regular exercise
halved the risk of dying for people with stage II and III colon cancer.26 Similar findings
were reported by Giovannucci for prostate cancer.27

Sunlight
Sunlight and vitamin D may improve prognosis for breast cancer, as well as colon,
prostate, leukemia, lymphoma and even melanoma.28 Vitamin D levels may be checked
by simple blood tests and ideal calcidiol levels are probably 100-250 n mol/l29 or more
specifically 120-150 n mol/l.30

Marriage
Tominaga found that following surgical treatment of primary breast cancer, being a
widow reduced survival by one third whilst having a hobby doubled survival.31

Group therapy
Spiegel reported in the Lancet 1989, that attending a group based upon emotional
expression, weekly for one year, doubled survival time for women with secondary breast
cancer and some participants survived over 10 years.32

Another trial was performed by Fawzy with 68 patients with early stage malignant
melanoma. 33 At 6-year follow-up those who had usual care plus stress management
showed a halving of recurrence (7/34 vs 3/34) and much lower death rate (3/34 vs 10/34;
p=0.03) than the group with only the usual surgical management. Both groups also had
their immune function monitored which showed that after being originally comparable, the
stress management group had significantly better immune function after six months.

Other studies have also yielded promising results in terms of longer survival for liver,34
gastrointestinal malignancies,35 and lymphoma36 but others have shown equivocal or
negative results.37 38 39 40 41 The last of these trials was a large-scale attempt to replicate
the findings of Spiegel. The results of this trial were negative despite the fact that the
effects of the intervention had a positive effect on quality of life and mental health.

Of the five negative or equivocal trials mentioned above only two reported a positive effect
on mental health and quality of life while all the studies that showed a positive effect on
survival reported improved mental health and quality of life. Therefore, the trend seen in
eight out of ten cancer studies seems to be similar to the findings in studies of psycho-
social support in heart disease; where a psychosocial intervention improves quality of life
and mental health it has the ‘side-effect’ of prolonging survival, while if there is marginal or


9



no long-term benefit on mood or quality of life there is no corresponding improvement in
survival.

Meditation
There are no properly conducted, specific trials to date investigating the survival benefits
of meditation, but Meares published case reports of remission from secondary breast
cancer (in the liver and the breast) following intensive meditation.42 43 44

More recent research is suggesting a range of physiological and psychological benefits
from practicing meditation many of which have implications for cancer. These include
improved sleep45, elevation of melatonin levels46, improved pain control47, improvement
of depression48, anxiety and coping49 50, and improved immunity.51 As such, independent
of potential effects on survival, meditation should be considered as an option offered to
patients to improve their coping with cancer and symptom control.

Traditional techniques
Yoga and qigong are two therapies that have been utilised extensively in the East over
many centuries. Quality of life studies affirm benefits, but again survival benefits remain
to be studied using Western scientific methods. Massage falls into the same category.

Creative activities
Art, music and dance are amongst another range of therapies waiting to be studied more
analytically.

Personal development and transformation
Faller found that poor coping, distress & depression was linked to lower survival52, while
Penninx found that depression in the elderly doubles the risk.53 Greer found that women
with breast cancer who demonstrated a “fighting spirit” as compared to denial or stoic
acceptance, increased their chance of survival significantly.54 Likewise, psychotherapy
and involvement in self help techniques proportionally associated with quality of life
experience and survival duration have been demonstrated by Cunningham.55

Spiritual factors
A review of 71 research articles by Hawka indicated that imagery, meditation and group
support activities may address spiritual health, resulting in beneficial outcomes of
enhanced physical and emotional health and decreased cancer mortality.56

Lifestyle factors and side effects
The side-effects of healthy lifestyle change are by-and-large healthy. It is obviously
important to tailor the lifestyle change to suit the cancer patient’s personal preferences,
level of fitness or motivation and at the same time to take care that the patient does not
form unrealistic expectations nor forgo important treatment.

Lifestyle research summary
Tables 3 summarises the benefits of lifestyle interventions for women with breast cancer.


10


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