Hi, I'm Dr. Meroë Morse, an assistant professor
of Integrative Medicine at MD Anderson Cancer Center.
And today I'm joined with Dr. Santhosshi Narayanan,
associate professor of Integrative Medicine here at MD
Anderson Cancer Center.
And this is the Cancerwise Podcast.
Welcome, Santhosshi.
Thanks for being here.
Today, we're here to talk about what cancer patients need
to know about vitamins and supplements.
Thank you for having me, Dr. Morse.
I look forward for our conversation.
I think it's a very important topic.
Patients are very vulnerable when they're going through
cancer journey, and they have a lot of questions about what
they can do for their health.
Wonderful. I think this is a really important topic as
well. One study showed that about 70% of
patients who are receiving treatment for cancer are taking
some form of supplement or vitamin, and this is really
important for their primary physicians to know.
And it's wonderful to be able to speak
with them and give them advice on
moving forward with the safest, most effective approach.
So, I look forward to chatting with you about this.
I think cancer patients are uniquely vulnerable
to misinformation and wanting
to do everything possible to help
treat their cancer, and this vulnerability drives
a real desire to get information,
but also make decisions and implement
practices that aren't always the safest for them.
I agree, it's a very tough spot for patients to be
when they're dealing with a cancer, and to be in the cancer
journey, and being lost with all the misinformation, and
glad we are talking about it today.
Absolutely. Another point is, I think a lot of clinicians
want to be able to have this conversation openly and
transparently with their patients.
They don't want their patients to be withholding
information out of fear that they're going to be judged,
or that that something negative will happen.
And yet, this is not really something that we were
taught in our training.
It's becoming more and more common to
give clinicians a framework of how to discuss that.
But you and I wrote a paper about this very topic.
Could you give us a rehash of
that paper and how we have recommended
to approach this?
Yeah, absolutely.
So, open communication, where we create a space
for the patients to discuss about supplements is very
important. So, in our paper we thought about
how to create this framework.
Like, what are all the things that we need to consider when
we are talking about supplements?
We first obtain the list of supplements that patient
wants to use. And then we go over the risks and benefits.
What are the risks of combining the supplement with their
chemotherapy or with radiation?
What are the adverse effects of such supplements?
What organ toxicity that these supplements can cause?
So, these are all the factors that we consider in our
consultation with our patients.
And in the paper that we wrote together, I think
we put that together in the form of
a flowchart where we classify the supplements based on
the risk and benefit.
So, if the, if a supplement has a high risk and low
benefit, then there is no point in using it.
Whereas if a supplement has medium risk
and medium benefit, then we have that conversation with the
patient and understand what is the patient's
goals. What are they looking for?
Is that to decrease the side effects?
Can we do something else like acupuncture, for example,
to help with the joint pain which is caused by letrozole or
other aromatase inhibitors.
So, things like that which can be managed,
symptoms which can be managed by other measures,
which does not involve the use of supplements, which
can actually interact with a potential chemotherapy.
I think that kind of framework that we put together
in that paper helps decision making by clinicians,
by oncology providers at MD
Anderson, and also outside to come up
with a plan on what they can do
to help their patients safely
handle their supplements.
And I think the framework is valuable.
But also, we need to consider the personalized approach.
Every patient has a different cancer type.
They're at a different stage of their cancer treatment.
A lot of them are using newer agents.
And and each of these immunotherapies
and chemotherapies have different interactions.
So, it's not a one-size-fits-all approach.
We can't just hand them a paper saying take these
supplements or don't take these supplements.
It really requires that nuanced conversation and certainly
establishing this clinician-patient
relationship. To continue the conversation is the most
important part that they are trusting
of us, and that we have their best
interest in mind. It's very interesting to me
to meet each patient where they are and
speak with them, and have an educational
conversation about moving forward with
the best case approach.
Can you share with me some of the more common
herbs and supplements that you've been seeing in your
clinic these days? I think there's often a pattern.
So, what are you finding patients are taking or asking
about these days?
So, recently I see that a
lot of patients are using artificial intelligence
to create a supplement list.
That is one trend that I've been seeing in my clinic.
People usually need a read about it and they create their
own list. So, some of the supplements that I see
that other patients use are mushroom supplements.
People like to use some mushroom teas, then they use
mushroom capsules.
Then a lot of people use vitamins and
other herbs. Some people use astralagus,
which is an antioxidant.
Some people use ashwagandha, which comes from traditional
Ayurvedic medicine. People use turmeric capsules.
People use green tea capsules.
So, people use a lot of things.
And the other pattern I see is that sometimes
it's very unclear if it is specific to their
cancer. For example, turmeric is a blood
thinner. So, one patient
may not experience an adverse effect from turmeric,
but another patient with a brain tumor with a potential
bleeding, they may bleed more into the tumor
and may not realize it.
It might happen because of turmeric.
And there is also some hepatotoxicity reported.
So if a patient already has elevated liver enzymes,
then there may be a risk.
And similar situation happens with green tea extract,
as you know.
We both know that green tea has EGCG, which
is highly potent. At the same time, when people use green
tea as pills instead of drinking as tea,
there is a risk of liver toxicity.
So, balancing this and helping patients
to make an informed decision about their care and
making an informed decision about the supplement to use,
I think is important in our practice.
So on a similar note, I was thinking, I'll ask
you what you are seeing in your clinic?
I do see a lot of turmeric use and green tea extract
use. And you completed a certificate in Ayurvedic
medicine on top of your integrative training.
And I remember you and I did a talk last year
regarding herbs and supplements, and we showed
the research on the uptick of hepatotoxicity
in the, in the setting of tumeric.
And what I found to be so interesting is the,
in the supplement world, which is not a regulated world,
and I think it's important for our patients to know that,
that although it's a $5 billion a year industry,
it is not regulated by a body
like the FDA.
And so, the quality of supplements
is variable. There can be adulterants the content
and the potency is really difficult to maintain.
When we saw the addition of piperine,
the black pepper component, into tumeric supplements,
we saw the rates of hepatotoxicity double
in the liver tox case series.
And I think that speaks to the potency
of of tumeric and black pepper in that combination
and how plants are very powerful.
But it also speaks to the
the vulnerability of the consumers and how
they may not have realized that this new
this new formulation had increased toxicity.
Most patients aren't monitoring their labs when they're
taking these supplements. They don't think they need to
because it's a na- it's a natural product,
quote unquote. So, I do see a lot of tumeric
and green tea extract in, in my clinic.
Because we work very closely with our patients with breast
cancer who have a lot of side effects related to the
treatments, I do see some patients taking
formulations that are intended to help with hot flashes,
some of those vasomotor symptoms.
And my concern whenever I
hear about this and look deeper into it, is that these
herbs have estrogenic potential.
So, they have the potential to, to stimulate estrogen
release or, or stimulate the estrogen receptors
in the body and, and
certainly in hormone positive breast cancer, that's
something we're trying to avoid.
So, while we don't want them to be having these negative
side effects related to the endocrine therapy,
we also don't want them to be doing something potential,
potentially harmful.
This is where I, I love to be able to
explore the benefits of non-pharmacological
approaches to, to side effects like our acupuncture
treatments and our massage therapists, so really
leading them towards safer, non-pharmacological
alternatives. I do see a lot of vitamin use
in, in the clinic, and so I would love
to talk on a few of the more popular vitamins
that I come across. And I'd love to have you chime in.
Vitamin D, we know from the VITAL study, is
a very important vitamin for immune
health, certainly for bone health.
And the VITAL study found that patients
with cancer who had vitamin D levels replete
to a normal level tended to have better outcomes
in their, in their cancer journey.
And so, that is really important information.
It's an intervenable test that we can,
can make moves on.
I will say, though, that a lot of
patients tend to overdo it when they are taking
vitamin D. The thought that, well, if a little bit is good,
then maybe more is better.
And that's not entirely true.
So, I have unfortunately been seeing an uptick
of hypervitaminosis D
levels above 100 and the side effects
that come with it. So, this is something where we want to
be very cautious and measure, make sure they're
being dosed properly.
So, vitamin D is important, but
in moderation. The other vitamin group
is B vitamins.
I wonder if you see that a lot in your clinic.
I do, actually, very often.
So, I see hypervitaminosis D,
and, as you mentioned, it is good to
check the level and then dose it appropriately
because we know that in patients with bone
metastases, there is a risk of hypercalcemia
which will have other adverse effects, and it may harm
the patient. So, it's always good to check and also
B. So, we know that in studies
excess B6 has been shown to be toxic,
especially neurotoxicity.
And sometimes patients take B6 and B12
to help the neuropathic symptoms, which happens with chemo.
And it is thought that that is going to help the
neuropathy. But actually it may harm because
excess of B6 can cause neurotoxicity.
So, I suggest usually to,
for patients to check the levels and then take it, or
we would check it in our clinic and then dose
it appropriately so that we protect the our patients from
toxicity. And in terms of other vitamins
I see similar pattern like you.
Yeah, the B vitamin is very interesting.
And I always have patients read labels.
So, so that's one other kind of safety aspect.
If they have the, the vitamin bottles or the supplements
available to them, I ask them to bring it
to the visit and we review what the amounts are
on the back. And most of the the B complexes
that I see have levels upwards of 1,000%
daily value. One brand has 44,000%
daily value of B12.
So, while we want to be repleting
low vitamins, we also don't want to be overdoing
it.
There's mounting evidence to show that excess
B12 might have an association with colorectal
cancer. We saw that in the B-PROOF study.
It was a secondary analysis.
I think testing is paramount.
We want to make sure we are neither
too high or too low, but kind of Goldilocks-style, just
right. The other vitamin that patients often
will chat with me about or inquire about is
vitamin C, particularly high dose vitamin C
delivered through intravenous therapy.
Do you see that in your clinic?
Yeah, I do see that too.
I get a lot of questions about IV vitamin C
and also oral vitamin C.
I see that a lot of patients are on oral vitamin C,
and I always worry about the antioxidant effect of
oral vitamin C.
And when it comes to IV vitamin C, we know that a
systematic review showed mixed results.
So, the the evidence is not in
favor of using IV vitamin C in cancer.
There is also a risk of financial toxicity for our patients
because it is very expensive.
I'm sure more studies will give us more answers on what
is the right approach on, on these areas
of some IV infusions, IV vitamin
infusions. But I would like to reiterate a couple of points
that you mentioned for our patients.
So, one is "all natural" does not mean "all
safe." So, supplements are "all natural,"
but it doesn't automatically mean that it is going to be
safe. So, natural compounds, natural supplements also
have side effects. And the second is appropriate dosing.
That is another point I would like to reiterate because
something which is safe, something which is shown
for cancer prevention, cancer control,
important in cancer does not mean more is
good. Appropriate levels are always beneficial.
So, testing is better than just blindly taking
it.
Like pharmacotherapy, like prescribed
medication doses, dosages make a huge difference.
So, you know, melatonin is a good example.
At a very low dose, we know that that is more of a sleep
aid supplement.
Melatonin is a natural hormone that our brain makes
that helps us to get to sleep.
And we do a lot of things in our daily lives
to suppress melatonin production, like reading screens,
being, being in an artificial light.
And so, a lot of patients will take melatonin to
help with sleep.
The higher doses of melatonin,
ten milligrams or up, paradoxically cause
wakefulness. So, this is another example where too
much of a good thing can actually be working against you.
And patients don't realize that.
So, really, the details are very important
here.
Dr. Morse, I heard that you have an interesting research
article that you're writing on gut microbiome.
So, could you please tell us a little bit about probiotics
and what you found in your research, and
how we should educate our patients on the use of
probiotics?
Yeah, absolutely. And thank you.
I am very close to
publishing an article on the microbiome gut-brain
axis and how our gut microbiome impacts
our nervous system. So, look out for that.
We at MD Anderson have a wonderful team
of physician researchers who
explore the microbiome, so I won't go into too much detail
about the, the clinical research behind that.
Just to say that there's a lot of ongoing interest
in how the gut microbiome changes
through food and how that impacts outcomes in,
in cancer treatment.
Particularly, the melanoma team has been very forward
thinking in this realm.
I always, I always talk to patients
about the power of their their gut microbiome and
how their food choices can really
impact the way their body has inflammation,
the way their immune system can respond
to the treatments they're receiving, and
generally how food can be medicine in this way.
So, a lot of patients will either be already taking
probiotics or ask me what the best probiotic
to take is. And I try to, as always,
understand a little bit about why they're taking a
probiotic if they are.
Some patients do take probiotics chronically
for very specific medical conditions,
and that's important for me to know because I wouldn't want
to disrupt this balance of flora.
But most patients will just be taking it because they've
heard that it's good for their gut health.
And in those situations, I like to explain
that having a diverse microbiome
is really the healthiest thing they can do, and
they can't always get that from a
single probiotic pill.
The probiotic pills often will have 1 to
10 different strains in there,
and that is not going to allow for the diversity
of the microbiome that we're really looking for.
When we analyzed the stool samples of people who are on
probiotics, we see, actually, in most
cases, a very limited diversity compared to
people who are eating prebiotic and probiotic-rich
foods. So, this is where I really try to educate
patients on the power of fiber, prebiotic-rich
foods like your cruciferous vegetables, probiotic
foods. So, fermented food sources like yogurt,
kefir, kimchi,
sauerkraut and figure out ways that they can incorporate
that into their eating patterns.
Do you have recommendations for patients
from the Ayurvedic perspective on
fermented foods and probiotics?
Yeah. So, there is some recommendations which are
which comes from an Ayurvedic perspective, not specifically
on the pre- and probiotics, but Ayurvedic diet
recommendations would naturally improve the microbiome.
As you mentioned, the gut microbial diversity
is connected to immune system.
A shoutout to our melanoma team for helping us
understand that in greater depth.
And I look forward to reading your paper and learn more.
But I think the nature of
the microbial diversity is such that naturally, if
patients can develop it and help it grow further
with fiber, that is always beneficial.
And when it connects to Ayurveda as,
I just graduated from master's in Ayurveda, so there was
quite a lot of learning to do, and I'm still continuing
to learn Ayurveda.
So, Ayurvedic diet is very personalized.
So, we recommend AICR, the American
Institute of Cancer Research-based diet in our clinic
and our practice.
And it is, it's along the lines of those.
But it adds in an additional layer
of personalization for each individual.
So, in Ayurveda, people are classified based on
their body constitution.
And we just submitted a book chapter for
Society of Integrative Oncology, where we expand on this
for people to learn about how we classify.
So, that's a very detailed process.
And once you are able to understand the body constitution,
we can make adjustment in their diet based on their
body constitution.
So, that will help personalize the diet.
But gut microbiome when a person eat
healthy diet rich in fibers, vegetables as you
said, cruciferous vegetables, other vegetables, plant-based
proteins, beans, lentils, Ayurvedic diet is heavy
in lentils and beans, it helps the gut microbial
diversity.
I would love to hear a separate podcast on Ayurvedic
practice.
I think right now we're at a point where
a lot of patients are seeing us during their
cancer treatments, and so they may be off of
their supplements at the recommendation of their oncologist
or their surgical team or their radiation oncology team.
But we also see patients in survivorship mode
who are finished with their treatments and they're being
monitored. And they, a lot
of them are enticed to restart
some of the supplements that they had been on or that that
they had withheld during their treatment.
Can you speak a little bit about survivorship stage
of cancer, and whether the same rules apply,
or if a different perspective is used for supplements
in survivorship?
Thank you Meroë. That's a very important question
because often I see patients in my clinic who would
come to me because they have completed their
cancer treatment, and now they want to restart their
supplements, and they want to know if it's okay
to restart the supplement.
And first of all, I would like to thank them for making
that appointment and not taking it on their own,
because it is very important that they discuss it with us.
And sometimes in the setting of survivorship, as you
know, the interaction part is not worrisome.
So, we don't have the interaction
with chemotherapy and radiation to worry about.
But we still have other concerns.
The other concerns being are these supplements
indirectly helping the tumor growth?
So, in earlier part of our conversation you were talking
about the estrogenic effects of some supplements.
So, I worry about that, too.
So, in my patient with a hormone positive breast cancer
or other hormone-dependent cancer who have completed their
treatment, is this supplement going to help
fuel the cancer cell growth, which otherwise
may not happen? So, that is my worry.
So, I often talk to patients about it and
and tell them that the supplement that they are taking may
have estrogenic effects or estrogenic potential,
or other hormone-stimulating potential.
So, that is something to watch out for in survivorship
setting. And the other concerns that
I will discuss openly with my patients
is the side effects,
because the side effect still remains the same.
We discussed about the green tea and on the hepatotoxicity
and cases of hepatotoxicity from turmeric
reported in Europe.
So, these are some of the concerns which are still there.
And now that they're in survivorship, they probably are
also getting less monitoring.
So, the adverse effects may not even be known
or it may not be caught early.
So, I think one needs to be cautious in this setting,
too. And again, as all of our
approach is about open
communication, I think that having that conversation,
open communication and following up with patients
at even during survivorship and having that conversation
on integrative approach to survivorship, which
includes discussion on herbs and supplements, and using
non-pharmacological approaches.
We both know that ASCO-SIO, American Society of Clinical
Oncology and Society of Integrative Oncology, combine
guidelines are very supportive of use of
non-pharmacological approaches.
And these guidelines are put together by many experts
with a very detailed review.
So, we know that based on evidence, there are so many
non-pharmacological approaches that we can do.
And if patients want to, want to take supplements,
a proper guidance and helping
them understand what is what and what side effects
are happening, and directing them
to food sources can be helpful so that their
supplement list can be smaller.
For example, often people ask me about medicinal
mushroom supplement and we published a systematic
review. I reviewed almost 2,300 papers
in the last ten years to see what was the effect
of mushroom supplements on people with cancer.
What does the study show? What we found is that mushroom
supplements had a mineralogical potential.
They do have very low side effects.
They do improve quality of life.
But there is also
one study which showed that the immune effect,
the positive stimulation and the inhibition may happen
with the same mushroom supplement in the same population.
So, we need to clarify what happens in terms of
immunological effects.
And there is a risk of liver toxicity also.
So, that is another thing to think about.
And people are also taking other drugs even though it's not
cancer drugs. And for example, reishi mushroom interacts
with cytochrome P450, which is a common metabolizing
enzyme for many of the other drugs.
So, other drug interaction risk is always there.
So, I think survivorship is an important area and
careful discussion and guiding the patient patients
appropriately and full disclosure
by patients of what they're taking to Integrative Medicine
team is very helpful in making sure that people are safe
and they're able to make informed decisions.
Absolutely. And I think that systematic
review on the mushrooms is such a helpful piece of
literature for integrative oncologists out there who are
looking for more guidance.
So, kudos to you for, for digesting
that information.
And I hope that there is additional research.
The strength of the evidence base is growing.
And for now, I think the the evidence in
lifestyle, in the role of nutrition and all of the various
types of nutrition and diets that are out there, is really
growing. The role of exercise and physical
activity is very strong.
So, this is where I lean into in my clinical practice
and, and try to reduce pill burden for
patients and really empower them to make these changes.
So, I'm glad to see that we have similar clinical
experiences and an application to
our integrative training.
Yeah. Yeah. Dr. Morse, can you tell us
a little more about what we want our patients
to know in terms of our practice
like diet, exercise, mind-body stress
reduction, social, spiritual aspects?
Can you expand a little bit more for our patients?
Well, of course. We want to see patients
wherever they are in their treatment journey.
And and the virtual door's always open to
discuss everything from a lifestyle perspective
to a psychosocial spiritual perspective.
When the body is supported both
mentally and physically, it has the potential
for great healing. And that's what we do in our Integrative
Medicine Center. We we really try to
optimize patient-centered approach and
apply these lifestyle interventions
and spiritual interventions, if
that's what is important to them, to
a personalized toolkit, I like
to say. So, I think there are always areas
where we can improve upon in nutrition and exercise,
making sure that they're prioritizing sleep and not
relying on pharmacotherapy, and then making
sure that they're embracing their community, whatever that
looks like to them.
All of these have been shown in the research to work
synergistically to really optimize health
and optimize the body's healing potential.
So, every patient is different.
We, we approach it in a very personalized way.
But essentially, getting to these basics
is as what I think our consults are about and
why patients appreciate meeting with us and
feeling reassured with what they're already doing, or
having this new knowledge to to move forward
and make a difference instead of sitting around
worrying about what what will happen with their
their cancer. So, I think an integrative
approach is very empowering for patients.
Yeah, I agree that is wonderful.
And I'm so fortunate to be able to work with our
team, yourself.
I learn a lot by talking in a formal setting and informal
setting, as we always do, and we have a team
of our nutritionists that we we learn from, learn
from each other, psychologists and physical therapists
and mind body specialists, yoga therapists, music
therapists and acupuncturists and massage therapists.
And it's a blessing to be able to have that team
at MD Anderson so we can offer a real,
whole person approach to our patients.
And I think that helps the patients and patients appreciate
it, and we are able to address them as
a whole person. And I think it is very important when
people are dealing with a very distressful
situation in life, such as their cancer journey.
So, I feel fortunate to be able to have the team of
people that we work with and offer our services
to our patients.
Absolutely. We work with some expert
healers in our clinic.
Santhosshi, thank you so much for joining me today.
This was wonderful to talk about herbs and
supplements with you. I thoroughly enjoyed our
conversation.
Thanks for having me today, Meroë.
It was wonderful conversation and look forward to speaking
more with you.
And thank you for tuning in today.
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