THRIVING After Cancer, An Interview with Lise Alschuler, ND, FABNO
According to the National Cancer Institute, there were more than 15 million cancer survivors in the United States as of 2016, which represented nearly 5 percent of the population. The number of cancer survivors is projected to steadily rise over the next few decades, reaching more than 26 million by 2040. The most common cancers these survivors have experienced include breast, prostate, colorectal, gynecologic, and melanoma.
SARAH COOK:
You have devoted your career to post-cancer care for the last 15 years. How has your experience shaped your philosophy over time?
LISE ALSCHULER:
I spent my first 10 years as a physician practicing general naturopathic medicine. It was only when I had the opportunity to work at a cancer specialty hospital that I began to adapt all of those naturopathic teachings to the application of post-cancer care. What struck me at the time was that patients were receiving the best that conventional medicine had to offer, yet they still had so many unmet needs.
It was then that I began to view naturopathic medicine as a uniquely special addition to the overall care plan for these patients. The integrative approaches that I had used for a decade in my general practice all applied seamlessly to the specialized area of post-cancer care.
I’ve found that naturopathic and integrative approaches are perfectly suited for addressing the unmet needs of patients who have experienced cancer in their past. Integrative approaches not only optimize wellness, but also address risk factors, comorbid conditions, and treatment sequelae in cancer survivors.
COOK:
Can you describe a typical patient experience during cancer survivorship?
ALSCHULER:
I can describe a typical patient experience, but that doesn’t mean this is everybody’s experience. We need to first differentiate between two distinct categories of cancer survivors: those who have undergone curative-intent treatment and those who have cancer as a chronic disease. For this interview, I will only be discussing those who have completed treatment with curative intent. These patients have been declared “cancer-free” by their oncologists and don’t have an active disease process.
The most common scenario is that patients will finish cancer treatment, be congratulated that their cancer is gone, receive a figurative pat on the back, and be sent on their way. I have had cancer survivors describe to me that upon completing treatment, they feel like they have been pushed to the edge of a cliff, they are looking out over the abyss, and they are going to fall. They need a lot of support, and a congratulations is not enough.
As many as 75 percent of cancer survivors are dealing with symptoms that are either direct side effects of treatment or lingering effects of the cancer itself. Many of them have more than just one symptom. In addition to not feeling like themselves, they often have a fear of recurrence, made all the more acute with their renewed sense that life is valuable and precious. They have endured a harrowing experience and now have a deeper desire to achieve wellness. Cancer survivors are highly motivated to create change so they can live happier and healthier lives.
Many cancer survivors return to their lives and try to fit back into the space they filled before cancer. This doesn’t typically work. The lingering effects of treatment slowly dissipate, and they must find a new normal. During this process of readjustment, many of their needs go unattended—including their fears of experiencing cancer again and their motivation to make healthier choices. If we ignore their unique and unmet needs at this time, it’s a lost opportunity.
COOK:
You mentioned that most cancer survivors experience lingering side effects of treatment. What are some examples?
ALSCHULER:
Some of the side effects of cancer treatments—like nausea, vomiting, hair loss, and appetite changes—are typically short-term. Other side effects can linger over time. One of the most common, long-lasting effects of cancer treatment is fatigue. It’s a deep and persistent fatigue that cannot just be slept off. Cognitive changes, anxiety, depression, sexual dysfunction, lymphedema, peripheral neuropathy, and pain are other side effects that can persist over time.
It’s important for clinicians to also be aware of the side effects that can manifest after treatment is complete. For example, some cases of peripheral neuropathy may not appear until several weeks after the last dose of chemotherapy. Osteoporosis may develop years after some types of chemotherapy, hormone therapies, or steroid medications. Palpitations that develop months or years after treatment with doxorubicin (Adriamycin) could be a result of this medication’s cardiotoxic effects.
Cancer survivors are a vulnerable population. They need diligent monitoring for late-onset side effects as well as immediate support to navigate the lingering effects of cancer treatments.
COOK:
When supporting cancer survivors, is there a need to understand the intricacies of specific treatment side effects, or is it sufficient to support them with a general holistic approach?
ALSCHULER:
We can help our patients tremendously if we address them holistically. Again, we are talking about patients who have completed cancer treatment with curative intent, have been deemed “cancer-free,” and have no active disease process. Integrative approaches to support digestive, hormonal, immune, and cellular health will boost their overall health and well-being.
That being said, some of the lingering effects of cancer treatments are unique in their pathophysiologies. Knowledge of the specific pathophysiologies allows us to better support related biochemical and cellular functions.
One example is change in cognitive function. After completing cancer treatments, some people struggle with word recall, multitasking, and attention. They become easily distracted and have trouble concentrating. Many refer to this as “chemo-brain,” but that’s somewhat of a misnomer. The phenomenon is driven by cytokines and neuroinflammation. Cytokines cross the blood-brain barrier and disrupt neuronal function. Thus, an integrative approach must lower neuroinflammation along with optimizing neuronal cell-to-cell communication.
Another example is fatigue. There are at least three underlying factors in its pathophysiology: hypothalamic-pituitary-adrenal (HPA) axis function, mitochondrial function, and nutrient status. This explains why a good night’s sleep is not sufficient and why we should consider adaptogens to support the HPA axis, antioxidants and flavonoids to support mitochondrial function, and trace minerals and vitamins to optimize nutrient status.
COOK:
What are the priorities when assessing health status in cancer survivors?
ALSCHULER:
A top priority when working with cancer survivors is being able to determine whether new symptoms are benign, or if they’re potential signs of cancer recurrence. People who have had cancer will ask, “Is this my cancer coming back?”
Clinicians need to feel confident in responding to that situation. Know the metastatic patterns of various cancers, such as the tendency for breast cancer to spread to the liver or bones. Investigate symptoms that are constant, unremitting, or worsen over time because these are more characteristic of recurrence or metastases. Offer patients reassurance if their symptoms come and go or dissipate over time. It’s common sense, but this is a delicate population. You don’t want to alarm patients, but you also don’t want to miss a recurrence.
The next priority is to evaluate biomarkers related to nutrient status, inflammation, oxidative stress, blood-sugar homeostasis, and HPA axis function. The experience of cancer and cancer treatment can disrupt any or all of these biochemical functions. The assessments help us individualize recommendations to support underlying biochemical pathways and cellular health, which will improve quality of life in cancer survivors.†
We can evaluate inflammation with cytokine profiles, C-reactive protein (CRP), homocysteine, and the neutrophil-lymphocyte ratio (NLR). The NLR is one of my favorite biomarkers to assess because we can quickly calculate it from a complete blood count (CBC), and it’s highly correlated with underlying inflammation. I’m also excited about a test that people can self-order that measures urinary 11-dehydrothromboxane B2, which is a simple measure of cyclooxygenase activity.
Closely related to inflammation is oxidative stress, which we can evaluate with specialized lab tests for oxidative status, oxidized LDL cholesterol, or 8-hydroxyguanosine (a direct assessment of DNA oxidation). The simplest way to assess blood-sugar homeostasis is to calculate the homeostatic model assessment of insulin resistance (HOMA-IR) from a fasting glucose and insulin. HOMA-IR should be less than 2.5. The simplest way to assess the HPA axis is with the salivary four-point cortisol and DHEA test.
Many people ask me about hormone assessments after breast cancer. The problem with measuring estrogen fractions after cancer treatment is that systemic levels are affected by treatment and do not correlate with estrogen levels at the local tissue level. A better assessment for patients who have been treated for hormone-sensitive cancers is genetic testing for single nucleotide polymorphisms (SNPs). SNPs related to estrogen metabolism help us determine how estrogens are being metabolized and if they need specific metabolic support.
Finally, we should assess psychological stress. This can be done as part of the interview or with validated questionnaires. Statistics show that being socially isolated is an independent risk factor for cancer recurrence. Social isolation not only reduces the quality of life, but also influences physical health of cancer survivors.
COOK:
What’s the role of diet in supporting cancer survivors?
ALSCHULER:
The most well-researched diet to reduce the risk of cancer and other chronic diseases is the Mediterranean-style diet. It’s rich in vegetables, fish, nuts, seeds, and high-quality oils to support blood-sugar homeostasis and metabolic health. The diet is also rich in phytonutrients and antioxidants that support cellular and DNA health. For cancer survivors, we don’t need to make it any more complicated than following a whole-foods, plant-based, Mediterranean-style diet.
Also, emerging evidence suggests that when we eat might be as important as what we eat. The simple act of fasting overnight for at least 13 hours is correlated with lower inflammation, better glucose stabilization, and lower risk of cancer recurrence.
COOK:
How can dietary supplements support immune and cellular health in cancer survivors?
ALSCHULER:
Diet, exercise, and lifestyle lay the foundation of supporting immune and cellular health in cancer survivors. I view dietary supplements as a way to fill in the nooks and crannies. You can see in my protocols that I recommend several different products, but nobody needs to take everything. Our recommendations always need to be individualized.
Plant flavonoids are potent supplements to support antioxidant status as well as cellular and DNA health.† Flavonoids often work best in combination, but many people don’t want to take multiple pills. I formulated ProThrivers Wellness Flavonoid with the goal of packaging several well-researched and synergistic flavonoids into a single product. The green tea extract, curcumin, transresveratrol, glutathione, and quercetin are all in forms that have been shown to be highly available when taken orally.
Melatonin is another core supplement to support the health of cancer survivors, with more than 400 clinical studies demonstrating benefits. Melatonin supports hormonal, immune, and cellular health.† Mushrooms and vitamin D provide additional support for immune health, and my goal for an optimal serum 25(OH)D level is 40-80 ng/mL.†
We can provide antioxidant support with alpha-lipoic acid (ALA), glutathione, and tocotrienols.† Tocotrienols are the smallest member of the vitamin E family, and are more potent than other forms of vitamin E in terms of their ability to support antioxidant status.† Depending on the person, we might consider a multivitamin and omega-3 fatty acids for further nutritional support.
Although it’s not a dietary supplement, I include sunscreen in my list of recommendations for cancer survivors because we need to be mindful of protecting their skin—particularly in those who have received radiation.
COOK:
How can dietary supplements and homeopathics support energy in cancer survivors?
ALSCHULER:
I recommend supporting energy by supporting mitochondrial function and HPA axis function. Nutrients to support mitochondrial health include coenzyme Q10 (CoQ10) and acetyl-l-carnitine.† The most extensively researched adaptogenic herb to support HPA function in cancer survivors is American ginseng (Panax quinquefolius).† These three supplements can be used in combination for their synergistic effects.†
For those with more debilitating fatigue, I often use Bioplasma cell salts. These are homeopathic trace minerals that revitalize cellular function.‡ We don’t know the exact mechanisms of how they work, but I find they’re useful during the immediate post-treatment phase when energy is often at its lowest. Once a person maintains more stable energy, we can switch to trace minerals for ongoing nutritional support.
COOK:
How can dietary supplements support cognitive function in cancer survivors?
ALSCHULER:
I formulated ProThrivers Wellness Brain because I couldn’t find a supplement that was as comprehensive as I wanted to support cognitive function for cancer survivors.† I often use the ProThrivers Wellness Brain as a foundation and add in more support as needed. The product contains lion’s mane (Hericium erinaceus), acetyl-l-carnitine, citicoline, and curcumin.
Lion’s mane is a mushroom, so it supports immune as well as cognitive function.† It’s also been shown to support nerve growth-factor synthesis and neuroplasticity.† Acetyl-l-carnitine provides mitochondrial support and has been shown to support a healthy mood.† Citicoline is required for the rate-limiting step in acetylcholine synthesis and is a component of neuronal cell membranes. It’s been subjected to a Cochrane review and shown to support healthy cognition.† Curcumin is included in the branded form of Theracurmin because this form has been shown to cross the blood-brain barrier.
COOK:
How can dietary supplements support mood, sleep, and sexual function in cancer survivors?
ALSCHULER:
The experience of going through cancer treatment can be so emotionally stressful for people, and the fear of recurrence is common among cancer survivors. Adaptogens can support a healthy stress response, and other herbs and nutrients can help calm the mind.† Lavender oil extract is my first choice to support people with an anxious mood.† It’s reliable and has no drug interactions. L-theanine can be combined with lavender oil extract during the day because it supports a sense of calm while maintaining mental alertness, whereas kava kava is better used at night.† Phosphatidylserine, B vitamins, and trace minerals are good options to support HPA axis function and a healthy stress response.†
Sleep is so important to support overall well-being of cancer survivors, but many people struggle to achieve restful sleep because of changes in HPA axis function or the psychosocial overlay of stress and fears of recurrence. Melatonin is an excellent option to support sleep in cancer survivors because it not only helps regulate the circadian rhythm, but also supports immune function.† Magnolia bark extract contains a compound called honokiol, which supports sleep and better mood.† Melatonin and magnolia bark are combined with magnesium and l-theanine to provide synergistic calming support in the ProThrivers Wellness Sleep formula.†
Sexual function is another concern that many cancer survivors struggle with. Changes in sexual function after cancer treatment can include changes in body image, desire, arousal, or performance, or discomfort during sexual activity. I’ve found that herbal supplements to support sexual function are not a magic bullet, but they do gradually and subtly support sexual function over time.† It’s helpful to ask cancer survivors about changes in sexual function because this isn’t information they might openly volunteer.
COOK:
What practical tips can you share with practitioners who are new to working with cancer survivors?
ALSCHULER:
Be clear about whether you are willing to work with patients who have completed curative-intent treatments or with those who have cancer as a chronic illness. These are two distinct populations with different needs.
In this interview, we’ve talked only about how to support cancer survivors who no longer have active disease. We haven’t discussed patients with ongoing cancer as a chronic disease, but that doesn’t mean these patients should be ignored. They are defying the odds, and they need integrative care. Bring them into your practice, but be sure to work closely with their oncologist, research their medications and side-effect profiles, and reach out to other integrative practitioners for help. Join the Oncology Association of Naturopathic Physicians (OncANP) or the Society for Integrative Oncology (SIO) for continuing education opportunities.
†These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.
‡Claims based on traditional homeopathic practice, not accepted medical evidence. Not FDA evaluated.
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