* CHAPTER ONE WHAT NOW? YOU'VE JUST FINISHED TREATMENT FOR CANCER, AND YOU HAVE BEEN TOLD THAT you are cancer-free. After months or years of treatment--including major surgery and rounds of nauseating chemotherapy and scarring radiation-- you've achieved your goal. You can go back to your old life as though none of this ever happened! Or can you? When you go through treatment for cancer, there is a clear end goal: remission and beating your disease. But when the day comes that your oncologist bids you adieu, with just an appointment card for a 3- or 6- month follow-up appointment, that farewell can feel . . . anticlimactic. He's done what he can for you, and your cancer is in remission. You are essentially healthy again. Oh, you'll be coming back to see him once in a while for a checkup, but you can finally pick up your normal life and move on. This is a joyful moment! But once the initial relief wears off, many patients find that instead of feeling ecstatic, they feel uncertain, frightened, and out of control. They've heard so many stories of recurrence, and they've heard the prognosis after recurrence can be dire. Instead of providing an action plan to fend off the threat of a relapse, few oncologists offer anything in the way of advice or care following the end of treatment. After fighting for your life with a team of experts, you are on your own with no compass to guide you. For some patients, the time following their treatment for cancer can be more emotionally fraught than the time during treatment itself. During treatment, they are focused on getting better, and they have a team of passionate professionals working toward that goal. Co-workers rally around them, and friends and family show up with casseroles and offer rides. Everything is focused on killing the cancer. When treatment is over, the team of professionals disappears. The need for rides and casseroles also disappears. Physically, you feel much better, and it's high time you got back to your life. But getting "back to your life" isn't always possible or even desirable; you've been through a life- changing experience. The fact is, the end of treatment may not mean going back to your old life at all. You aren't out of the woods yet and still have those follow-ups to contend with. THE SWORD OF DAMOCLES For many people, the stress they feel about their future health is debilitating. At least during cancer treatment, they were fighting it. Of course, it's natural to worry about the future. But excessive worry and anxiety about possible hazards in our path can prevent us from living life to its fullest. There is an ancient story, told by the Roman orator Cicero, about a man named Damocles. Damocles was envious of the power and possessions of his ruler, Dionysius, whom he served at court. Dionysus was well aware of Damocles's jealousy. He shrewdly proposed that they switch places, to allow Damocles a firsthand taste of the fabulous benefits of royalty. Damocles greedily accepted the invitation. He was escorted to the throne room, where he was surrounded by treasures, exquisite food and wines, silk fabrics, precious metals, and beautiful courtiers. As Damocles sat upon the great throne, the king advised him to look up toward the ceiling. There, above the chair, hanging solely by a single horse-tail hair, was a large and deadly sword. Damocles quickly jumped off the throne, declaring as he departed that he no longer wished to experience the luxuries of power if they were paired with such risks. In his fifth Disputations, Cicero asks: "Does not Dionysius seem to have made it sufficiently clear that there can be nothing happy for the person over whom some fear always looms?" Imagine how differently Cicero's story would have been had Damocles stepped calmly from the throne, ordered the removal of the hanging sword, and then resumed his longed-for adventure. Fortunately, we can remove the metaphorical swords that hang over our lives. Contrary to the advice of many oncologists, we now know there are things we can do to significantly reduce the risk of recurrence. In a pleasant irony, taking physical action to prevent recurrence can lead to a more positive outlook, and there is scientific evidence that our attitude affects our body's well-being, as well. AFTER CANCER CARE It is now well known that lifestyle does have an effect on some types of cancer. According to the World Health Organization, 30 percent of cancers are related to lifestyle or infections: "More than 30% of cancer could be prevented, mainly by not using tobacco, having a healthy diet, being physically active and moderating the use of alcohol."1 These are not the words of naturopaths, integrative oncologists, or vegan nutritionists. These are the words of one of the world's most established-- and conventional--health organizations. In our practices, we have seen how diet and lifestyle can also help individuals prevent recurrence of cancer. Significant medical research has established both theory and practical application of the links between nutrition, exercise, stress, and cancer recurrence. These principles are beginning to change the face of cancer treatment centers around this country and the world, and many hospitals currently have integrative cancer care centers as part of what they offer patients. However, there is more to be done. Integrative oncology--the acknowledged term for cancer care that blends cancer-killing medicine with other lifestyle and immune-supporting practices--is actually an oxymoron. Oncology, the study of tumors and ways to attack them, is only a part of integrative cancer medicine. The rest is in the person who has the malignancy and that person's individual terrain-- that is, the microenvironment within which tumor cells live. This microenvironment is finally beginning to be a focus of laboratory researchers; we are at the dawn of a new era. We use the term integrative oncology for convenience, and generally everyone knows what that means, but we prefer the term integrative cancer medicine. THRIVING POSTCANCER Most published data in oncology measure the value of a given intervention in terms of "survival." We don't just want our patients to survive; we want them to thrive. All of the recommendations we have made in this book have scientific support. Some of the evidence-based studies required to achieve FDA approval are included, but also small clinical trials and epidemiologic, demographic, or laboratory studies that show evidence of benefit from lifestyle changes for those who have or have had cancer. Some examples of the latter include increasing immunity, regulating DNA and protein production in cancer, increasing psychological and spiritual well-being, and enhancing overall health. The key to incorporating the advice given in this book is to apply the "risk-benefit ratio," a philosophy that lies at the heart of all good medicine. That is: How does the risk of using any given treatment or procedure balance with the benefits that might be achieved? Doctors routinely use a risk-benefit ratio when performing surgery. Is the risk to the patient--of death, postoperative attack, disability, and cost-- worth the benefit he or she will likely receive, such as a longer life and an improved quality of life? If the benefit outweighs the risk, we recommend surgery. In the case of our basic recommendations in this book, there is minimal risk and the opportunity for great benefit. Light exercise, improved diet, and practicing stress-management techniques have universally positive benefits. When intensifying exercise, making drastic diet changes, adding supplementation, or taking medication for anxiety, the risk-benefit ratio may be more of a balance and should be undertaken under the supervision of a doctor. For example, a rigorous exercise regimen could lead to injuries for previously sedentary people; a vegan diet could lead to anemia if there is not sufficient B12 in the diet; certain supplements can be contraindicated with certain medications; and antianxiety drugs can have side effects. Terrain We also need to broaden our approach so that we don't only fight against cancer. We tend to think about cancer treatment as a war, but we can move from a nasty internal terrain that's in turmoil to one filled with relaxation, peace, hope, trust, empathy, and compassion. We need to nurture our body, mind, and soul. After Cancer Care can provide a structure for a healthier diet and physical lifestyle, as well as support an informed decision-making process, enhance hope and utilize the wisdom and experiences of exceptional patients, reduce hopelessness and helplessness, reduce social isolation by providing support groups and other group activities, and offer instruction on stress-reduction practices. From a conceptual viewpoint, we loosely associate the two approaches of conventional oncology and complementary and alternative medicine (CAM) with the left and right brain. Conventional oncology is a military model of attack on tumors. It's very "left-brained"--logical, linear, and evaluated by statistical methods. It categorizes and systematizes, whereas CAM is a holistic approach designed to support multiple host systems with many types of intervention. CAM is thus more a product of the "right brain": Intuitive and nonlinear, it individualizes rather than systematizes. The goal of oncology is to destroy tumor cells in the body; the goal of CAM therapies is to increase host resistance to tumor cells by changing the internal terrain of the body. There is good evidence that we do better when we use both sides of our brain, which is the way we can view integrative cancer medicine. Some early studies--the significance of which may not have been understood at the time--profoundly demonstrated the impact of terrain. In 1975 Beatrice Mintz showed that injecting teratocarcinoma cells into an adult mouse caused a lethal cancer, but when injected into a mouse embryo, the tumor genes were expressed but healthy mice developed. More than 30 years earlier, researchers had discovered that the Rous sarcoma virus, which creates lethal sarcomas when injected into adult chickens, had no effect on chicken embryos.2 Dr. Mina Bissell repeated these experiments with the Rous sarcoma virus in the 1970s and found the same thing. She then went on to discover that the virus only forms a tumor in a wound, not in healthy tissue.3 Clearly, the environment (terrain) of a tumor cell or a tumor- inducing virus has a profound effect on whether or not tumors form. Similarly, tumor cells have been found in the bone marrow of patients with ductal carcinoma in situ, which can also be called stage 0 breast cancer.4 This is an indication that even in the earliest precancer conditions, tumor cells far from the breast can also be present. The significance of this finding is that these noninvasive breast cancers are frequently treated by local excision +/- radiotherapy--both of which are local (within the breast) treatments. Whether individual tumor cells found in blood or bone marrow ever grow into dangerous tumors or not depends a great deal on their environment, or the internal "terrain," which is produced by the sum total of diet, lifestyle, metabolism, environmental exposures, and stress. Traditional Chinese medicine (TCM) has had this view for millennia--that cancer is a systemic disease and the tumor is just a symptom of it. In TCM one must alter the underlying constitution in order to heal the disease. This may be the direction we are moving in integrative cancer medicine. A metaphor illustrates this: We know how to look for the seeds, but we have not really learned how to assess the soil, the microenvironment, and the internal terrain. The study of terrain is beginning to gain traction in mainstream cancer research now. It may be that cancer cells with a permissive terrain equal a tumor, while cancer cells in a nonpermissive terrain never develop into a diagnosable tumor. Dean Ornish, MD, a clinical professor of medicine at the University of California, San Francisco, did a groundbreaking study, published in 2008, in which prostate cancer patients on "active surveillance" changed their diets, exercised, did yoga, and meditated. It was very similar to the lifestyle and diet interventions that Dr. Ornish did in his original cardiovascular studies. After 3 months, patients' prostates were biopsied. After just a 3-month interval of this diet and lifestyle intervention, a shift was shown in the expression of more than 200 genes. The genes associated with biological aggressiveness "downregulated" (their expression was turned off), and the genes associated with less aggressive behavior "upregulated" (turned on). Inflammatory genes were also downregulated; it is well understood that cancer cells thrive in an environment of chronic inflammation, so this was also beneficial.5 We don't yet know how these effects are brought about. Maybe more available nutrients are directly affecting the tumor cells or are influencing the terrain or microenvironment; or maybe they are doing both. It is very likely that the changes are mediated through the process we call epigenetics--that is, the regulation of gene expression by our internal terrain. This is an entire area of study in itself and very much relates to what is done in integrative cancer medicine. In Part Two of this book, we undertake an in-depth discussion of the new science of epigenetics. YOUR AFTER CANCER CARE If you are very lucky, you have an oncologist who is fully or partly on board with the premise that your actions following your cancer treatment can affect your outcome. He or she may refer you to a nutritionist, advise you to alter your diet, recommend an exercise regimen, or refer you to a counselor or support group. But let's assume you are like most patients who are in remission. Your oncologist has given you a "clean bill of health" and asked you to call her or your primary doctor with any new problems. Otherwise, she'll see you back in her office in a few months. You are given little additional guidance as to what you should be doing in the meantime. It's up to you to create your own after cancer care plan. That's where we come in. The first thing we recommend you do is make an assessment of where you are coming from, where you are now, and where you are going. It is time to take a look at some good habits--some may be new to you, some you may have adopted long ago--that will support and maintain your remission from cancer and promote your continued good health. We suggest you keep a journal when doing this. Excerpted from After Cancer Care: The Definitive Self-Care Guide to Getting and Staying Well for Patients with Cancer by Gerald Lemole, Pallav Mehta, Dwight McKee All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
