complete prostate cancer care: how to integrate the best of conventional and complementary medicine...

Complete Prostate Cancer Care: How to integrate the best of conventional and complementary medicine Rob Rutledge, MD, Radiation Oncologist Associate Professor, Dalhousie University CEO, the Healing and Cancer Foundation

HealingandCancer.org OVERVIEW OF TALK Basics of prostate cancer Essential concepts for treatment decision-making Hormone therapy side effects and treatment How to get the best medical care Must-do healthy lifestyle habits An approach to complementary therapy

HealingandCancer.org AGE # of new cases 50

HealingandCancer.org Prostate cancer in Canada in 2011 Each year: 26,000 men diagnosed, 4000 deaths

HealingandCancer.org Dont turn slow growing prostate cancer cells into fast growing cells Damage to the normal prostate cells causes them to turn into prostate cancer cells Further damage to slow growing prostate cancer cells cause them to become fast growing cells Whats good for preventing prostate cancer is good after a diagnosis Whats known to cause prostate cancer should be avoided

What is prostate cancer: A laypersons guide

HealingandCancer.org WHAT IS PROSTATE CANCER? Prostate cancer occurs when some cells in the prostate begin to grow in an uncontrolled way Each mans prostate cancer is different Majority are very slow growing cancers

HealingandCancer.org THE INSTRUCTIONS IN THE CELL Each cell has the control centre (nucleus) Instructions manual is made of words and sentences (DNA)

HealingandCancer.org WHEN CELLS DIVIDE One parent makes two daughter cells The new cells are exactly the same The same control centre The same book of instructions

HealingandCancer.org How prostate cancer cells are made Prostate cancer cell is a normal prostate cell with many mistakes Three ways the mistakes are created: 1) Born with mistakes genetic is rare 2) Accident when cell divides - mutation 3) Substance causing cancer - Carcinogen Fatty diet, agent orange Firefighters are at higher risk

HealingandCancer.org PROBLEMS WITH THE CELLS INSTRUCTIONS If the instructions read: STOP dividing after coming in contact with the lining of the prostate gland is changed to KEEP dividing after coming in contact with the lining of the prostate gland The cell wont stop growing!

HealingandCancer.org PROBLEMS WITH THE CELLS INSTRUCTIONS If the instructions read: Grow slowly if testosterone is on the receptor is changed to Grow QUICKLY if testosterone is on the receptor The cell will keep on dividing quickly

HealingandCancer.org WHAT IS PROSTATE CANCER Normal prostate cell that has begun to grow in a fast and uncontrolled way Requires dozens of changes to the cell Cancer cells will grow into normal tissue After more changes can get into lymph and blood system to grow colonies at a distance (metastasis)

HealingandCancer.org

HealingandCancer.org Risk factors for prostate cancer Age and being male testosterone Family history Double risk with one 1 st degree relative 5 times risk with two 1 st degree relatives Diet.

HealingandCancer.org USA - Black USA - White Canada

HealingandCancer.org Poor diet increases risk of prostate cancer Animal fats Red meat especially if well done Dairy products Transfats Diet low in vegetables (want >4 servings per day) Alcohol if more than 5 drinks per day Folic acid and zinc from too much supplementation

HealingandCancer.org OBESITY AND SUGARY DIET Prostate cancer risk increases with increasing weight Associated with higher waist to hip ratio Increased weight associated with more aggressive prostate cancer. Insulin and insulin-like growth factor released with sugary foods prime cancer cell turnover

HealingandCancer.org Dont turn slow growing prostate cancer cells into fast growing cells Whats good for preventing prostate cancer is good after a diagnosis Whats known to cause prostate cancer should be avoided

HealingandCancer.org EACH MANS CANCER IS DIFFERENT Each cancer has different mistakes and a different personality One man cannot compare their cancer to any other Any man can always do better than expected!

HealingandCancer.org HOW A TUMOUR GROWS A tumour is a collection of cancer cells A tumour starts as one cancer cell 1 cell then 2 then 4 then 8 .. Tumour growth if more cells are made than die Tumour doubles in size over 1-3 years or longer Tumour - 1 cm in size has a billion cells

HealingandCancer.org HOW PROSTATE CANCERS CAUSE PROBLEMS Problem in the prostate Narrow the tubing urinate more often Spread to lymph nodes uncommon Spread to other parts of body especially bones Affect whole body - fatigue

HealingandCancer.org Prostate Specific Antigen - PSA A chemical produced by both normal prostate cells and prostate cancer cells Inflammation / infection of the normal prostate cells causes the PSA to increase Whether or not prostate cancer cells are present Explains why the PSA can bounce up and down

HealingandCancer.org PSA Screening vs. Follow up PSA screening is for men who do not have a diagnosis of prostate cancer and do not have symptoms Men who have symptoms like problems with urination should see their doctors right away My view: By age 40-50 all men should have a conversation with the family doctor about screening Once there is a cancer diagnosis, PSA is an excellent test and predicts what will happen years in advance

HealingandCancer.org PSA does not localize cancer cells Prostate cancer cells produce PSA no matter where they are in the body A rapidly rising PSA and a very high PSA likely means there are cancer cells beyond the prostate area Eg. PSA doubling time 50

HealingandCancer.org MAKING THE DIAGNOSIS Biopsy - take a piece of tumor and look under microscope 8-12 cores of tissue each measuring 1cm by 0.1cm This is a tiny sampling of the prostate gland May miss cancer completely May miss more aggressive cancer

HealingandCancer.org Gleason Score how aggressive is the cancer Score is out of 10 Made up of two grades, each out of 5 First grade is the most common cancer seen Second grade is the second most common cancer Gleason score 6 or less is slow growing Example 3/5 plus 3/5 Gleason score 8 or more is fast growing Gleason 7 is neither fast nor slow

HealingandCancer.org STAGING OF PROSATE CANCER Rectal exam - T1C, T2, T3 PSA - 20. How quickly it has increased Gleason score and how much cancer is seen on the biopsy Optional: Bone scan Cat scan MRI Genetics look at the genetic mistakes to predict how aggressive the cancer is

HealingandCancer.org

HealingandCancer.org Cross section of bone with a single cancer cell

HealingandCancer.org Active surveillance Means watching PSA and re-biopsy of prostate every 1-2 years if curative treatment is being considered Go on to curative Rx if PSA jumps quickly, urinary symptoms, or biopsy shows worsening cancer Best for men with very slow growing cancers whose life expectancy is less than 10-15 years ** Dont want to turn slow growing cancer cells into fast growing cells

HealingandCancer.org Treatment for cure: operation Radical prostatectomy removes the prostate and seminal vesicles Has a specific side effects Related to major operation Urinary incontinence Erectile dysfunction Is an excellent option in a situation where prostate cancer cells are likely restricted to the prostate gland Removing the prostate gland provides much more information about the aggressiveness and extent of cancer Radiotherapy can be used after surgery if it looks like cancer is likely left behind in the surgical bed or if PSA begins to rise in follow up

HealingandCancer.org PSA after a prostate operation PSA should 0 if all normal prostate cells and cancer cells have been removed An undetectable PSA does not mean there are no prostate cancer cells left in the body It takes hundreds of cancer cells to produce enough PSA for the blood test to detect it A rising PSA after an operation means that there are cancer cells in the body

HealingandCancer.org PSA after radiotherapy PSA rarely gets down to undetectable value after RT because some normal prostate cells are still alive PSA can bounce around a little because the normal cells can get inflamed A rising PSA 2 points higher than the lowest PSA value means the cancer has come back Rare to recommend surgery or cryotherapy if cancer recurs

HealingandCancer.org PSA after hormone treatment Hormone therapy starves both normal prostate cells and cancer cells of testosterone Hormone therapy kills / disables over 99% of cancer cells and should bring the PSA down to an undetectable level Hormone therapy given as part of a curative plan increases the chance of cure Once the effects of hormone therapy wear off, testosterone will raise, and PSA levels will increase according to whether normal prostate cells or cancer cells remain Hormone therapy by itself is not meant to be a cure for cancer

HealingandCancer.org Treatment of cure: radioactive seeds in prostate Seed brachytherapy best for men with early disease when cancer cells likely in prostate gland of just beyond capsule Very high cure rates similar to operation when done by an experienced specialist Side effects Irritation of urinary tubing for 6 months Narrowing of urinary tubing in long term Erectile dysfunction in 50% over 5 years. Rectal problems rare

HealingandCancer.org Treatment of cure: radioactive seeds in prostate Picture here

HealingandCancer.org Treatment for cure external radiotherapy Technology has advanced in last few years to allow very high dose of radiotherapy to gland while minimizing dose to surrounding tissue Especially good for situations in which prostate cancer cells beyond capsule of the prostate but not spread elsewhere Side effects Irritation of the front part of the rectum bleeding in stool (5-10%) Irritation of the urinary tubing and bladder Erectile dysfunction in at least 50%

External beam radiotherapy

HealingandCancer.org Technological advances in Radiotherapy High-dose conformal radiotherapy IMRT IGRT Protons High dose brachytherapy All: Spare the normal tissue, deliver as high a dose as possible to cancer cells

HealingandCancer.org Treatment for cure: adding hormone therapy to radiotherapy Six months up to 3 years Can increase the chance of cure by 5-10% Increasing effectiveness of radiotherapy And/or killing off cancer cells floating in blood stream This is the same type of hormone treatment that is used if the cancer becomes incurable

HealingandCancer.org Long survival times even after recurrence 2007: 70-year-old very well executive PSA rising up to 9.5 Biopsy shows Gleason Score 9 (fast growing) Lump in prostate is confined Bone scan and cat scan show no obvious spread He goes on a clinical trial Hormones for 2.5 years, full dose radiotherapy, and weekly chemotherapy during the radiotherapy His PSA is undetectable for 4 years

HealingandCancer.org Long survival times after recurrence Example case May 2011 PSA is 0.07 (testosterone is low normal) His exam is normal November 2011 PSA is 0.15 (testosterone same) Doubling time is about 6 months Not defined as a recurrence until PSA >2 but likely incurable cancer now PLAN: Wait for PSA > 10-15 - this will take 6 doubling times or 3 years Start on hormone therapy will hold cancer in check for 3-5 years Last 2-3 years of life (or longer) will be on special chemo

HealingandCancer.org Long survival times after recurrence Example case He has many more years to live Dont turn slow growing cancer cells into fast growing cells He can do something about the side effects of hormone therapy which can influence his quality of life

HealingandCancer.org Side effects of hormone therapy Thanks to Dr. Shabbir M.H. Alibhai of University Health Network in Toronto for overview Loss of libido and erectile dysfunction from lack of testosterone Hot flashes Can try a medication (effexor) to help these Acupuncture and hypnosis may help

HealingandCancer.org Side effects of hormone therapy Bone loss and risk of osteoporosis / fractures Weight gain Decreased muscle strength Lowering of hemoglobin count by 8-15 g/L Mood changes mild depression, irritability Slight decrease in some mental function Diabetes Increase in lipids / cholesterol Slight risk of heart attack especially > 65 years old

HealingandCancer.org Osteoporosis & Fractures from hormone therapy Hormone therapy leads to progressive declines in bone mineral density (BMD) Range from 2-5% in first year, slower in subsequent years but never stabilizes 1,2 Seen across bone sites (e.g. hip, spine, wrist, forearm) Some recovery of BMD during off periods with intermittent hormone Rx 1. Isbarn I. Eur Urol 2009; 55:62 2. Wadhwa V. BJU Int 2009; 104:800

Normal Moderate Osteoporosis Severe Osteoporosis Courtesy Dr. A. Boyde

Age-Related Changes in Bone Mass

Age-Related Changes in Bone Mass with hormone therapy Hormones

HealingandCancer.org Prevention of osteoporosis Calcium/Vitamin D !!!! Supplements are insufficient to improve bone density (unless severe deficiency) but can attenuate losses 1000 IU vitamin D daily 1000-1200 mg elemental calcium from all sources All Men starting hormone Rx should have bone density measured at start and every 1-2 years

HealingandCancer.org Muscle atrophy/Frailty/Falls from hormone therapy 2.8% reduction in lean body (muscle) mass over 12 months of ADT use 1 Loss of upper extremity and lower extremity muscle strength and fitness compared to non-users of Hormone Rx 2,3 1. Haseen F. J Cancer Surviv 2010; 4:128 2. Basaria S. Clin Endo 2002; 56:779 3. Galvao DA. Prostate Ca Prostate Dis 2009; 12:198

HealingandCancer.org Cognitive dysfunction from hormone therapy 47-69% of men on hormone therapay had a measurable decline in at least 1 cognitive domain on formal neuro-psychological testing Domains most often affected were visuo- spatial and executive function 1. Nelson CJ. Cancer 2008; 113:1097

HealingandCancer.org Intermittent hormone therapy Used in place of continuous hormone therapy in the incurable situation Give 9 months of hormone treatment Example: 3 injections each lasting 3 months PSA should go very low then wait for PSA to surpass 10-20 REPEAT above (for years) until the PSA no longer goes down At which point its called castrate-resistant prostate cancer

HealingandCancer.org Intermittent hormone treatment Appears equally effective to continuous hormone therapy in controlling cancer Less declines in BMD, fatigue during off period Dependent on testosterone recovery Impact on other side effects uncertain

HealingandCancer.org Castrate-resistant prostate cancer Classic hormone therapy is no longer working including trying steroids (prednisone) Standard therapy has been chemotherapy for men who are strong enough and interested Best to see a medical oncologist about options

Mitoxantrone 19942002200420082011 Docetaxel Zoledronic acid Cabazitaxel MDV 3100 Denosumab Abiraterone Acetate Prostate cancer therapy milestones 60 Current Treatments Emerging Treatments

HealingandCancer.org First line therapy for castrate resistant prostate cancer Standard therapy is taxotere every 3 weeks combined with daily prednisone Reasonably well tolerated Lowering of blood counts, risk of infection Hair loss Numbness in extremities Many more

HealingandCancer.org Taxotere for castrate resistant prostate cancer 62 Petrylak, NEJM, 351: 1513, 2004; Tannock, NEJM, 351: 1502, 2004; Berthold, J Clin Oncol, 26:242, 2008

HealingandCancer.org Tumours growing despite taxotere can go on to new therapies Abiraterone (Zytiga) is a special type of hormone therapy which can block the testosterone production even better than standard hormone therapy Its given in pill form once daily along with prednisone Much easier than classic chemotherapy May cause mild high blood pressure and fluid retention, or lower blood potassium, or mild irritation of the liver Hope is to use this medication at earlier stages PLEASE ENROLL IN CLINICAL TRIALS

Abiraterone acetate Improved Overall Survival in Metastatic CRPC Overall Survival with new type of hormone therapy ABI7977366575202826820 Placebo3983553062101053030 21 Hazard ratio = 0.646 (0.54-0.77) P < 0.0001 Placebo: 10.9 months (95% CI,10.2-12.0 ) Abiraterone acetate: 14.8 months (95% CI, 14.1-15.4) 100 80 60 40 20 Survival (%) 0 0369121518 Placebo ABI Time to Death (Months) 3.9 months 64 de Bono et al. NEJM. 2011; 364(21): 1995-2005.

HealingandCancer.org Bone Builders for metastatic prostate cancer If cancer grows despite hormone treatment there is a high risk of cancer spreading to bone Using bone builders in IV (zometa) or Subcutaneous (Xgeva) can decrease bone problems like fractures, spinal cord compression and delay painful problems Keep taking vitamin D and calcium!!

HealingandCancer.org Complete Prostate Cancer Care Understanding whats happening to you Getting the best from the medical system Empowering yourself with healthy lifestyle Exercise, diet, sleep, weight control

HealingandCancer.org Purpose of Information Learn to speak the language of the medical system Increase your sense of control and well-being Help you make the best medical decisions Empower yourself with non-medical ways to improve your health and outcome

HealingandCancer.org Too Much Information? If information gathering is making you tired If you find conflicting information See your doctor to clarify Trust what you are doing is the best for you

HealingandCancer.org Best Sources of Information Your physician/oncologist - individualizes the information and gives you the best medical advice Prepare for these conversations by researching and understanding prostate cancer in advance

HealingandCancer.org Sources of General Information about Prostate Cancer and its Treatment Librarian at a cancer centre or hospital Prostate Cancer Canada www.prostatecancer.ca Canadian Cancer Society - www.cancer.ca 1 888 939 3333

HealingandCancer.org How to Get the Most from the Health Care System Learn to advocate for yourself by: Preparing for each doctors visit Contacting your doctor/nurse if you have questions or concerns Drawing on extra services if needed Asking for a second opinion if needed

HealingandCancer.org Getting the Most from your Doctors Visit Before the visit: Create a concise summary of symptoms Bring a list of current medications and allergies Write down your questions before the visit Someone should accompany you Decide who will make record of the visit You may create a file with all your test results You can get a copy by visiting medical records

HealingandCancer.org Getting the Most From Your Doctors Visit Be honest and open Speak up if youre feeling overwhelmed: Im not sure I understand Wait until the summary then ask all your questions Take notes or record the interview Find out what to expect Know what to do for each side effect When do I need to act? Who you should call in case of problems?

HealingandCancer.org After Your Doctors Visit Keep a journal and list of results If need be ask for a family conference You are the most important person Call to clarify information or ask for appointment You are entitled to a second opinion Ask to speak to a different type of specialist

HealingandCancer.org Getting More Physical Care Multiple services are available in medical system Nutrition Psychology Home care nursing Rehabilitation Spiritual care Palliative Care Team Social worker can help coordinate if needed Ask your nurse or doctor for a referral Talk to an expert

HealingandCancer.org Dealing with Difficult Emotions Theres no one right way Find a wise person to talk to Realize emotions change with time Be kind to yourself

HealingandCancer.org When to Get Help with Emotional Problems Emotional distress is expected but if you: Feel overly depressed e.g., crying constantly Are withdrawing from all social contact Unable to enjoy life / feel hopeless Are so distressed cant decide on treatment Cant sleep because of anxiety Talk to a psychologist

HealingandCancer.org How to Get Help with Emotional Distress Tell your oncologist or nurse during the next apt. Schedule a visit to your family doctor Call the psychologist / counselor at the cancer centre Support groups

HealingandCancer.org Prostate cancer support groups Can help you with: Getting information Learning ways to cope Practical tips and support A safe place to express your emotions Improve quality of life!

HealingandCancer.org MUST-DO HEALTHY HABITS (stop slow growing cells from becoming fast growing cells) Diet. Vitamin D, Calcium, Omega 3 Exercise Maintain a healthy weight Sleep Practice relaxation

HealingandCancer.org The Importance of Nutrition Effective way to improve your overall health Individualize to what works for you Different diet during different phases of treatment Ask your doctor and/or professional nutritionist if persistent problems Weight gain Loss of muscle Side effects from chemo

HealingandCancer.org General Nutrition Advice Follow Canadas Food Guide recommendations www.hc-sc.gc.ca/fn-an/food-guide-alimentindex_e.html Choose a variety of food from all food groups daily 5-10 servings of fruits and vegetables/day Cruciferous vegetables brocholli and cauliflower Choose lower fat food groups Fat to make up < 20% of caloric intake Choose high fiber foods Whole grain breads and cereals Drink plenty of healthful fluids

Foods to Inhibit Prostate Cancer Cell Growth Garlic (100) Brussels Sprouts Spring Onions Leeks Broccoli Cauliflower Cabbage Onion Kale ~ Anti-Cancer Leaflet (D.S. Schreiber) Beets Fiddlehead fern Jalapenos Celery Turnips Orange Peppers Spinach Cucumbers Asparagus (65)

Breakfast Local/seasonal fruits Oatmeal/whole grain porridge Raw honey, maple/brown rice syrup Cinnamon Walnuts Smoothie Brown rice/pea/hemp protein, raw nuts or seeds, quinoa Unsweetened almond/brown rice milk Frozen locally-sourced berries Spirulina/Chlorella *Purchase organic as much as possible

Lunch Dark green leafy salad with Grated beets, cucumbers, kohlrabi Chopped walnuts, pecans, hazelnuts Dressing of cold-pressed, extra-virgin olive oil, raw apple cider vinegar, garlic Frittata with organic, free range eggs Sauted orange peppers and tomatoes in coconut oil, turmeric, garlic Sauted leafy greens and/or assorted sprouts Spelt flour traditional sourdough bread

Dinner Poached wild salmon with dill Quinoa Steamed kale/swiss chard sauted in organic butter and garlic Legume (beans/lentils) soup Add broccoli, cauliflower, celery Season with garlic, turmeric, black pepper, unrefined salt

HealingandCancer.org Taking Your Vitamins See your Doctor or nutritionist Omega 3 250-500mg per day Vitamin D 1000 IU / day Calcium 1,200 mg / day Healthy diet should provide the rest

HealingandCancer.org The Benefits of Exercise Effective way to improve energy, sleep, mood and overall health Improves strength and decreases risk of falls Data suggest 3 hours of vigorous exercise per week improves outcome Aerobic exercise - 3 to 5 times per week (20-60 minutes) Resistance exercise - 2 sets of 812 reps Balance exercises

HealingandCancer.org Complementary/Integrated Medicine Find a balance between doing research + following intuition Tell your doctor what youre taking and doing Dont forego proven treatments

HealingandCancer.org Conventional Medicine Scientific method relies on proof Clinical trials Documentation of toxicity Doctor as therapist / consultant Risks vs. benefits Prostate cancer - higher cure rates

"a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine Lynda Balneaves/CAMEO Body-based Mind-body Biologically-based Energy Whole systems What is Complementary medicine?

HealingandCancer.org Disadvantages of Complementary Medicine Can be expensive Some practitioners make unproven and false claims Some toxicities unknown Cancer centre librarian can do search on natural medicines database Beware of extreme diets Recommended daily intake of vitamins and minerals www.hc-sc.gc.ca/fn-an/nutrition/ reference/table/index-eng.php#rvv www.hc-sc.gc.ca/fn-an/nutrition/ reference/table/index-eng.php#rvv

HealingandCancer.org What to ask your Complementary Practitioner Credentials of practitioner Where they trained, for how long? Evidence of benefits of treatment Any randomized trials? Toxicity of treatment Documented? Does it interact with other medications? Benefit vs. risks? What is the total cost?

HealingandCancer.org There is no magic pill which cures all prostate cancer All the complementary medicines have been tested in scientific experiments Society of Integrative Oncology published report in 2009 based on evidence: Journal of the Society for Integrative Oncology, 7(3), 85-120

Massage and other Body-Based Touch Therapies Recommended: Massage therapy for anxiety & pain. Manual lymph drainage with compression bandaging for lymphedema. Caution: Massaging on or near radiation treatment field Excessive rocking motions for patients with nausea Not Recommended: Deep or intense pressure: Near lesions; enlarged lymph nodes, radiation field sites, medical devices, or surgery sites In patients with a bleeding tendency Lynda Balneaves/CAMEO

Meditation, visualization and other Mind-Body Therapies Recommended: Mind-body therapies practiced over time can reduce anxiety, mood disturbance, chronic pain, stress and improve quality of life and sleep quality. For Nausea and Vomiting Visualization, Meditation, Relaxation, Biofeedback, Prayer Caution: Hypnosis may cause dizziness, nausea, or headache when being brought out of a trance by an inexperienced hypnotherapist. Not Recommended: Hypnosis on individuals with psychosis or certain personality disorders Lynda Balneaves/CAMEO

Energy Therapies Recommended: Reiki & therapeutic touch are safe and may reduce stress and enhance quality of life. Caution: Limited evidence as to efficacy for symptom management, including reducing pain and fatigue Not Recommended: Bio-electromagnetically based therapies due to concern over toxicity and increased cancer risk. No controlled trials showing effectiveness for cancer treatment or symptom control

Acupuncture Regulates the flow of qi (vital energy) Needle, heat, or pressure stimulation on certain points on the body through meridians Causes nerve cells to release neurotransmitters, affects the pituitary gland, and changes function in parts of the brain Influences Blood pressure, Immune system Chemical release (i.e. endorphins) Deng et al., 2009

Mark Parisi Lynda Balneaves/CAMEO

Recommended: Poorly controlled pain, nausea and vomiting with chemo or surgery Acupressure wristbands on day of chemo for nausea & vomiting For hot flashes not amenable to pharmacologic treatment. Radiation-induced dry mouth Caution: More clinical studies needed to confirm benefit in: Shortness of breath or fatigue or neuropathy. Not recommended: If you are pregnant, have low platelets or white blood cells, severe thrombocytopenia, bleeding problems, or neutropenia AVOID acupuncture at tumor and metastasis site, limbs with lymphedema, and surgery sites Lynda Balneaves/CAMEO Acupuncture

Biologically Based: Natural Health Products Vitamins, minerals, animal materials, herbal therapies, biological supplements, dietary supplements, or combinations Used frequently by people living with cancer Evidence is lacking on some NHPs, but is a rapidly growing field of study www.mskcc.org/mskcc/html/11570.cfm www.naturaldatabase.com ods.od.nih.gov Lynda Balneaves/CAMEO

Credible Complementary Med Information UBC/BCCA Complementary Medicine Education and Outcomes (CAMEO) Program bccancer.bc.ca/cameo NIH - National Centre for Complementary and Alternative Medicine nccam.nih.gov/health/cancer National Cancer Institute Office of Cancer Complementary and Alternative Medicine cancer.gov/cam/health_index.html NEW! CAM-Cancer (National Centre for CAM, Norway www.cam-cancer.org

HealingandCancer.org Intensive lifestyle changes may affect progression of prostate cancer Ornish et al J Urol Sept 2005 174 (3) 1065-9 Randomized trial, n=93 men with biopsy- proven prostate cancer, psa 4-10, Gleason

complete prostate cancer care: how to integrate the best of conventional and complementary medicine...

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