PROVIDING INTEGRATIVE CARE I
Presenters: Keith Block, M.D. and Michael Schachter, M.D.
Moderator: Brian Doyle, M.D.
Commentator: Robert Wittes, M.D.
Session: F4; June 11, 1999
I. Abstract
In this session, Dr. Keith Block from the Block Medical Center and Dr. Michael Schachter from the Schachter Center for Complementary Medicine spoke about their integrative programs. Dr. Block uses an extremely comprehensive patient assessment system to design an integrative treatment plan, which includes both alternative and conventional methods. Dr. Schachter almost exclusively uses alternative methods in his treatment program. He discussed his program and the miscommunication he believes is occurring between oncologists and patients. He also briefly talked about the "clonal mutational theory of cancer".
II. The Program Presented by Dr. Block
Dr. Block gave a brief overview and then answered questions because he had just presented an in-depth plenary session on his program. Dr. Block’s program is designed to find out exactly who the patient is inside and out and how they take care of themselves. This allows the staff at his center to completely understand the patient and then a decision can be made on a treatment program. The methods they use to obtain a good understanding of the patient are: advanced lab analysis, physical fitness level, stress analysis, nutritional assessment, psychological state, etc. From the results of this intense assessment, a highly individualized treatment program is developed and hands-on training clinics are available for the patients to learn about each aspect of the treatment program.
The seven crucial parts to the programs of the Block Medical Center for healthier living are:
His program and philosophy on treatment is based on several years of observation and experience and published studies. In his presentation, he spoke about parts of his program and some of the published studies done in the respective areas that led him to include them in his program.
Physical Care: Exercise and physical care are an important component in Dr. Block’s treatment program. Some of the research that has prompted him to use exercise in his program is mentioned below. A cohort study was performed by the Chicago Heart Association on exercise. A person who has a 10 beat/min higher heart rate has a 26% higher risk of death from prostate cancer. This set a precedent for focusing on fitness in cancer care, which had not historically been done for cancer patients. Another study showed that cancer patients who did aerobic exercise and are fit do not experience fatigue while obtaining chemotherapy treatment. The amount of exercise needed to see this effect was not much: the patients rode a bike for 30 minutes/day.
At his center, Dr. Block and his staff do a complete assessment on flexibility, aerobic potential, and strength. From there they make recommendations on what the patient needs to do to be healthy. They have a full staff working with the patients to teach them how to exercise correctly. Also, they have many follow up appointments to ensure compliance.
Therapeutic Nutrition: The deficiencies that arise nutritionally from disease and conventional cancer treatments have been well documented. A study on women with early stage breast cancer showed that women who use tamoxifen and also change their lifestyle have a 6% improvement in survival rate than women who just used tamoxifen. The study also compared the British vs. the Japanese. British tend to have a diet high in fat, low in fiber, low in antioxidants, low in omega-3 fatty acids. Japanese tend to have a diet low in fat, high in fiber, high in soy, and high in omega-3 fatty acids. The Japanese had a 21% better chance of surviving. This is quite a significant difference that requires more research.
It has also been shown that fats can increase tumor growth and decrease immune function via prostaglandin E2 (PGE2). This leads to a decrease in survival. Sugar can have similar effects on PGE2, causing a decrease in immune function and thus decreased survival. Excessive protein has been reported to increase tumor growth but this is not consistent throughout the literature.
In the program at the Block Medical Center, they tailor a unique nutrition program for each patient to respond to the patient’s needs. Their main goal is to decrease fat mass and increase lean body mass, while keeping the patient well nourished. They have on-site training classes in kitchens to educate patients on the food they should be eating and teach them how to cook it.
Scientifically tailored supplement: At the Block Medical Center, they use nutrition combined with supplements or biological response modifiers. This must be done with "good thinking theory" and science behind it. One should know the studies about the supplements of interest before incorporating them into a treatment plan. This will help if contradictions are found in the literature.
Dr. Block mentioned one study involving a supplement. Retinoic acid (vitamin A) can impact p53 (gene that regulates cell division). If p53 is intact, it will initiate death to abnormal cells. Nutrients can increase intact (wild type) p53 in cells and decrease the amount of mutant p53 (which allows abnormal cells to live).
One problem with supplements is that the FDA has evaluated medical drugs very well but there is not a similar system used for supplements. Natural compounds have a larger margin of safety so a different evaluation system is needed in order to create certificate of analysis for each supplement and to standardize them.
Detoxification: Detoxification, the removal of harmful toxins and compounds from the body, is an important part of his program. There are two phases to detoxification. One must be careful when detoxifying because some detoxification programs can have toxic effects.
In summary, Dr. Block said it is important to develop unique treatment programs for each patient. He noted that he has never sat with a patient in his/her last days and heard them say that they wished they had worked harder. They always say, " I wish I chased my dream harder, strengthened my relationships, connected better with people, and played harder". Remember this and listen to it. Follow your dreams as if it were your last day!
III. The Program Presented by Dr. Schachter
Conventional cancer therapies include radiation, chemotherapy, surgery, anti-hormonal treatment, and immunotherapy. Dr. Schachter’s critique will mainly focus on chemotherapy and radiation.
The track record for cancer in the last 30-40 years has not been good with regard to reduction in incidence and mortality. Our focus on response to treatment is incorrect. Fortunately, this is finally beginning to change. Research in the last 30-40 years has been based on the clinical response to treatment via tumor size. A decrease in tumor size by 50% or more is considered a response to treatment. However, there is little correlation between tumor shrinkage and patient survival.
You may ask how this is possible? It is important to realize that a tumor does not consist solely of neoplastic cells. It also consists of the body’s defense cells that are trying to kill the tumor (natural killer cells, macrophages, etc.). When radiation and chemotherapy are used to fight cancer cells, the body’s defense cells are also being attacked and die along with the cancer cells. This is why there is no correlation between tumor size and survival.
Dr. Schachter is very concerned about miscommunication between oncologists and patients. He believes that patients should be better informed when they are given statistics on the chances that the treatment will produce a response. The response is often tumor shrinkage and not survival. If a doctor says that there is a 40% chance that the treatment will work, he may not be saying that there is a 40% chance of survival, but that there it is a 40% chance that the tumor will decrease by 50% or more.
Dr. Schachter believes that the most important step of an alternative and complementary program is education of the patient. This will allow for a clear-cut decision made by both the informed patient and doctor.
Dr. Schachter gave examples of how patients are not being informed by their doctors. He explained that with respect to breast cancer, women are often not informed that radiation treatment can decrease the chance of recurrence but does not prolong life. Also, the removal of the axillary lymph nodes does not influence survival, or quality of life (and actually may reduce it). It does not have any treatment value, or any effect on local recurrence. The only reasons axillary lymph nodes are removed are to determine the stage or the intensity of the treatment. Women are also usually told that they must have a lumpectomy and lymph nodes removed. There is no choice by the women. Dr. Schachter believes that women should be given the facts and allowed to make a choice on their own.
With regard to the prostate, a similar lack of education is seen. In 1994, the treatment men received with stages A and B prostate cancer were as follows: 51% had a radical prostatectomy, 27% received radiation therapy, 14% received hormonal treatment, and 8% received other treatments. Also, the awareness of people with respect to the different treatments are as follows: 70% are aware of radical prostatectomy, 63% of radiation treatment external beam, 41% of hormonal therapy, 34% of seed implant radiation, 27% of cryosurgery, 1% of diet treatment, and 8% of watchful waiting (no action, wait and observe, if symptoms arise, do something then). Prostate cancer is a very slow growing disease in most cases. For most men, they die of something else than their prostate cancer. Recently the early diagnosis of prostate cancer has dramatically increased due to prostate specific antigen (PSA) testing. The common treatment for men in their 50’s is radical prostatectomy or radiation. Radical prostatectomy leads to a poor quality of life and sexual impotence. This should never be done on a patient who is beyond stage A or B. These facts are often not explained to patients.
Dr. Whitmore at Sloan Kettering once said, "Is cure possible for those for which it is necessary and is cure necessary for those for which it is possible?" How good is conventional therapy for early stage prostate cancer? Of the conventional treatments such as surgery, radiation, seed implants, and cryosurgery, none have been clearly shown to have a positive effect on long-term survival. These findings appeared on February 12, 1997 in JAMA. "Fifteen-year survival in prostate cancer: A Perspective Based Population Study in Sweden". They showed that the 15-year survival rate for those who had versus those who did not have a radical prostatectomy is the same, 81%! The only randomized study of surgery vs. watchful waiting shows no difference in survival after a 23-year follow up (Journal of Urology and Nephrology, 1995). In three recent reviews of non-randomized studies, little evidence of a survival benefit was shown. A meta analysis on all the prostate cancer survival studies since 1980 on was published in 1993. The disease specific survival after 10 years was as follows: 93% of the patients who had surgery were still alive, 83% of the patients who relied on watchful waiting were still alive, and 74% of the patients who received radiation were still alive. To date, the 5, 10, and 15 year survival rates are no better with surgery, radiation, cryosurgery, and radiation implants than watchful waiting for early stage prostate cancer.
Can alternative treatments increase survival? The emphasis in conventional treatments is on tumor size and not on survival. Alternative treatments assume the body has the ability to heal itself under the proper circumstances. Much less emphasis is on destroying the cancer cells with destructive treatments that harm the body. More emphasis is on prevention, decreasing the chances of metastasis, and controlling the disease and on increasing the quality of life.
Alternative treatments are any treatments outside of radiation, surgery and chemotherapy. Alternative treatments include diet, nutrient injections, nutrition supplements, biomodifiers, herbs, homeopathy, mind-body techniques, massage, exercise, etc. Alternative therapies are used to boost the immune system and increase general health to build up the bodies’ defenses against cancer. Instead of the side effects of conventional treatments, an overall improvement in health is seen. While undergoing alternative treatments, it is important to closely monitor the disease via: measuring PSA levels, conducting digital rectal exams, power dopplers (tells blood supply going to cancer) and transrectal exams. If the disease is not controlled, it is necessary to intensify the alternative program or add conventional treatments such as a combined hormonal blockade.
Dr. Schachter described "the clonal mutational theory of cancer", which he stated is the genetic basis of cancer. The theory is as follows. Cancer is unregulated growth of abnormal cells. Such growth results from the accumulation of defects that can cause normal cells to become cancerous and cancer cells to become more dangerous and aggressive. As more mutations accumulate, the cancer cells become more and more aggressive. It results from a cell that changes characteristics due to a series of genetic mutations in the cell to a specific class of genes: tumor suppressers (suppress growth), proto-oncogenes (normally involved in controlling cell division) and DNA repair genes (make repairs in mutated DNA). A person needs to acquire at least 4 mutations to have clinical cancer. The more mutations one has after 4, the more aggressive the cancer.
How does one acquire mutations in their DNA? This occurs in many ways. Some examples are inheritance (small percentage), environment, lifestyle, stress, etc. It boils down to too much bad and not enough good. Bad are such things as petrochemicals, radiation exposure, insufficient exercise, etc. Good includes phytochemicals, antioxidants, exercise, etc. Alternative treatments are important in prevention but also in decreasing the aggressiveness of a cancer. (Refer to the 1995 Scientific American article that shows a good diagram of the clonal mutational theory.)
What are the implications of the clonal mutational theory for alternative and conventional treatments? Mutagenic agents may contribute to the development of cancer and may worsen an existing cancer by increasing the number of mutations in cancer cells. Radiation and chemotherapy are mutagenic. They kill cancer cells but also tend to cause mutations in cancer cells and normal cells. Recurring cancers are usually a lot more aggressive possibly because of this fact. There is some evidence of survival benefits with chemotherapy in breast cancer but not with radiation in terms of survival. There is no evidence of survival benefits for prostate cancer.
A man in the audience made a series of comments. He challenged Dr. Schachter on his ideas that he just presented on breast cancer and radiation. First he stated that in the "Vancouver study", they showed that using lymph node radiation when a woman had metastases outside the chest wall does have a survival benefit. Also, with lumpectomy patients, the original studies did not find an improvement in survival with radiation. But with long term follow up, 12-14 years after, women who only had a lumpectomy and not radiation had a worse survival rate due to recurrence.
Dr. Schachter’s response was cut short due comments in the audience. He said that there was one study reported in the New England Journal of Medicine in 1997 on radiation plus chemotherapy vs. chemotherapy alone. It showed that the combination therapy had a better survival rate. He did not want to go through his analysis at this time but would during the question and answer session.
He stressed that what he is trying to get across is that patients need to be educated on all treatments and they need to be given the facts. He is challenging doctors to have a different philosophy. Instead of telling patients that they must do this or that treatment, give them the facts and let them make their choices. Make sure that the patients know that alternative treatments attempt to reduce the occurrence of mutations and build up the body’s immune system. They assist the body’s defenses in fighting cancer with highly selective, non-toxic substances.
Dr. Schachter mentioned a small study reported in the Anti-Cancer Research Journal by Jaakkola in 1992 (vol. 12, p599). Eighteen patients with small cell lung carcinoma were given a mega dose of vitamins and trace minerals. At 6 months, only 50% of the patients who received no nutrients and just conventional treatments survived whereas 95% of the people who received nutrients and conventional treatments survived. At 2.5 years, none of the patients without nutrients survived whereas 40% of the patients with nutrients survived. At 6 years, that same 40% who received both were still alive. This program had no side effects. Surviving patients started the anti-oxidant treatment earlier than those who died. Patients who did the best are the ones who started the nutrient treatment early and then did conventional methods.
A book called Alternative Medicine’s Definitive Guide to Cancer by Goldberg is an excellent book. Dr. Schachter and his colleagues wrote Chapter 18 and his program is outlined.
Another study he mentioned was a small one that emphasizes the importance of synergistic nutrients. It was reported in the Japanese Journal of Cancer Research vol. 81, p1239, 1990. Their conclusions are that all of the vitamins work as a team. Female rats were given 7,12-dimethylbenz[a]anthracene DMBA (tumor promoter) on day 50 after birth. Some of them received a combination of 1, 2, 3 or 4 nutrients form day 40-240 while the others received none. The results showed that 100% of those receiving no nutrients got tumors. If one nutrient was given, 50% got tumors; with two nutrients, 30% got tumors, with three nutrients, 20% got tumors; when 4 nutrients were given only 12% got tumors. It is important to have a wide range of nutrients because they work as a team to fight the cancer.
The program Dr. Schachter uses at his facility includes the following:
Dr. Schachter discussed a series of about 10 case histories of patients whom he treated with little or no conventional treatments and mostly alternative treatments. They all did very well. In conclusion, Dr. Schachter emphasized that the alternative therapy philosophy should be applied to all patients at all stages of their diseases. More emphasis should be placed on prevention rather than on early detection. His recommendations are that we try to clean up our environments, focus on lifestyle changes, and educate patients on all of their options.
IV. Comments by Dr. Wittes
Dr. Wittes commented that Dr. Block and Dr. Schachter both have constructed very complex regimens that aim at getting to know the patient from top to bottom, back to front. He admires them for being so dedicated to patients that come to see them. He believes that the highly individualized programs are wonderful. He also noted that responses from the session showed that people are less interested in the method and more interested in knowing if the method they are using to treat cancer patients works. Dr. Wittes thinks that, although the integrative programs appear to work and are wonderful, research needs to be done to demonstrate that the package fulfills the promise. One problem with dissecting these complex regimens is that it is probably the whole program working together which makes them effective. But he believes that the regimens need to be studied for two reasons: 1. Studying the program will help generalize it for different people and different cancers, 2. Reimbursement from insurance companies will only occur if it is studied seriously and shown be effective.
V. Resources
Dr. Keith Block is Medical Director of the Block Medical Center and the Institute for Integrative Cancer Care. Access to information on Dr. Block and the Block Medical Center can be found at: www.blockmd.com.
VI. Audience Questions
If chemotherapy and radiation kill both healthy and abnormal cells, why don’t anti-oxidants do the same? (Why do antioxidants help kill cancer cells and protect normal?)
Preclinical evidence suggests that antioxidants do help both; however, in clinical practice and observation, this is not the case. The most likely reason why is because cancer cells are not able to readily take up the antioxidants. They are different, both biochemically and physiologically, than normal cells. Also, normal cells are primarily aerobic whereas cancer cells are primarily anaerobic, thus not allowing them to utilize antioxidants.
Do you know of any antioxidants that have unfavorable interactions with chemotherapy, radiation, etc.?
Neither of the presenters could name any but did make the following comments. Food derived antioxidants have not shown any bad interactions. Supplements on the other hand are different because it is easier to take too much. So they warned to be careful when taking supplements.
How does the clonal mutational theory of cancer explain childhood cancers?
First of all, children tend to get very different types of cancers than adults. The clonal mutational theory also applies to childhood cancers. A child could have been exposed to toxic substances in utero or exposed to a toxic environment right after birth. In combination with a few inherited genetic mutations, cancers can evolve.
Is there a book cancer patients can read on the nutrients knocked out by chemotherapy
Beating Cancer with Nutrition by Patrick Quilling is an excellent book for this.
An internist made some comments. He is known to use alternative techniques. Many cancer patients in his area to come to him for advice and treatment. He finds it very difficult to treat these patients because he doesn’t see them as a statistic. Everyone he sees has a different story and just doesn’t seem to quite fit into the current standards of treatment. He has a difficult time figuring out the best treatment for them. The conclusion he has made from his experience is that in every case, the patient tells him what he/she wants to do and with what they feel comfortable. He listens to the patients and what they want. This has been his guide for recommending treatment plans.
One of the speakers commented that another helpful thing he could do is consult with an oncologist with whom he trusts who has the same beliefs.
Journal of the National Cancer Institute has a full review coming out soon in Nutritional Oncology from the 1960’s to today.
Are genistein and soy the same thing?
Genistein is a part of soy. High doses of soy are always good but low doses of soy can actually stimulate breast tumor growth. Low amounts of soy can stimulate the estrogen receptor sites by acting as a weak estrogen; therefore, post menopausal women or women with breast cancer want to avoid low amounts of soy. They should eat lots or none at all. A suggested amount of soy is 20-40g/day.
Does a program of high dose nutrients interfere with radiation and/or chemotherapy as some oncologists say or does it enhance and reduce side effects?
This is not known yet. In his (Dr. Schachter’s) clinical experience, patients who use conventional treatments alone experience fatigue, are often bed ridden, and constantly feel sick. On the other hand, patients who use a combination of alternative and conventional treatments feel healthier, are not fatigued, often work full time, and do not feel sick.
Why are high does of intravenous vitamin C a common treatment for cancer now?
The reasoning is that cancer cells are severely deficient in enzyme catalase and superoxide dismutase. These convert hydrogen peroxide to oxygen and water. Ascorbate (vitamin C) intravenously at high doses induces the production of hydrogen peroxide in cancer cells and kills them because they cannot break down the hydrogen peroxide. Hydrogen peroxide then forms free radicals and kills the cells. There are no side effects. It is usually given as 50-100g over 4 hours.