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Home Support Coping Is natural always safe?

Is natural always safe?

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Is natural always safe?:

What should Oncology Patients Know about Complementary and Alternative Medicine

By Ella Starobinska, MD Candidate, Class of 2017, UofA COM- Phoenix



What is Complementary and Alternative Medicine?


Complementary and alternative medicine (CAM) are interventions that are not a part of traditional medicine. 1

Traditional medicine is standard medical care practiced by health professionals.

Complementary means being used in addition to conventional medicine, while alternative means used instead of conventional medicine. 2

CAM includes2:

alternative medicine

biological therapies- includes vitamins, minerals, probiotics, botanical, animal-derived products, proteins, amino acids, fatty acids

manipulative therapies and body-based therapies- encompass chiropractic, osteopathic manipulations, massage therapy reflexology, etc

mind and body medicine- interactions between brain, mind, body which can affect one’s health.

energy therapies- these therapies are based on the theory that people are composed of energy and therefore therapists in this field try to modify human health by using energy fields in the form of mechanical forces, vibrations, sound, electromagnetic forces, or visible light and magnetism.


What do we know about CAM therapies?


The popularity of CAM therapies among patients is increasing 1CAM use was reported to be between 7% and 64% among cancer patients from 16 different countries, with an average use of 31%. 3

People often turn to these for many reasons, including: 3

to relieve the side effects of chemotherapy

desire to find a cure and get all of the possible treatment options

desire to take personal control over their condition

What are the risks of using CAM?


In medicine when people evaluate medications, they consider how safe that medication is and how effective it is. The safety of a medication comes from its intrinsic properties of that medication, meaning it’s side effects) as well as how it was manufactured. The manufacturing aspect is very important because the medication will be affected if the materials that create that medication were misidentified, contaminated or substituted with another compound. Additionally, the same will apply if the product was incorrectly prepared, incorrectly labeled or misadvertised. 1

Unlike pharmacologic medications, many supplements do not have to be approved by the government before being sold on the market. They are not required to be standardized or event characterized. 3 Because of our lack of knowledge about these compounds leads many potential risks.


For instance, one study reported that 23.7% of 2609 traditional Chinese medical products from Taiwan contained synthetic medications (caffeine, paracetamol, indomethacin, hydrochlorothiazide, prednisolone). Some Chinese-origin herbal products contained NSAIDs (nonsteroidal anti-inflammatory medications which are often used as anti-inflammatory and painkillers) and benzodiazepines (a class of drugs with many uses including psychiatric and behavioral purposes). 4 These chemical compounds were not present on the labels of these herbal products which are supposed to be “natural”.


Pharmacologic drugs are composed of a perfectly measured, characterized, and quantified chemical compounds with exactly the same amount of the drug in every batch. Unlike these, supplements and over the counter herbal therapies have been shown to have variability between the quality of the same product between different companies and even between different batches of the same manufacturer. 3


Another problem is that the assumption that if something is indeed natural, it must be safe.3 Many of such products are in fact safe, however, this assumption is not true in many cases. One reason is that these supplements/herbal therapies can interact with medications and influence the effect of medical therapies- making them less effective and in some cases even more dangerous. Unfortunately, there is lack of studies and lack of knowledge about all of these products and about their interaction with pharmacologic medications.




Why is it important to disclose your use of Cam therapies to your physician?


Medical treatment, especially in oncology, is a team effort, which not only depends on the physician and the medical team but undoubtedly on the patient himself/ herself. A full disclosure and a discussion with the healthcare team between all the parties involved is important for better effectiveness of the medical therapy and better outcome for the patient.


It is especially important to tell your doctor about which supplements and herbal products you are taking , no matter how safe or natural you think the product is. This is especially important when receiving chemotherapy. Drugs that are used for chemotherapy are very toxic and are effective in a very small therapeutic range (a window in which a drug exerts its effects). Therefore, if a patient is taking a medication or supplement that can modify how effective or safe chemotherapy is, they might experience more side effects or make their chemotherapy ineffective against cancer. If this is the case, the doctor might advise you to stop taking this certain product and resume taking it after the chemotherapy regimen is completed. 3



What are some examples of these supplement- chemotherapy interactions?


The following tables contain some of the herbal supplements, which have been reported to have interactions with medications used in cancer therapy.


Figure 1: Interactions of herbal therapies with breast cancer medications. Modified from Arslan et al. (Arslan D, Tural D, Akar E. Herbal administration and interaction of cancer treatment. J Palliat Med. 2013;16(11):1466-1476. doi:10.1089/jpm.2013.0126.)






Chemotherapy Interaction

Astragalus (wild licorice)

Diabetes Heart disease Improve immune system

No significant side effects reported

Interaction with Cyclophosphomide

Black cohosh (horseradish root)

Menopause Sedation

Dizziness Headache Nausea Vomiting

Increases effects of Tamoxifen;

Increases toxicity of Doxorubicin, Docetaxel


Colon cancer Leukemia

Gastrointestinal symptoms (nausea, gastric irritation, diarrhea), bleeding

Numerous chemotherapy interactions, especially Doxorubicin, Cyclophosphomide

Echinacea (purple cone flower)

Improve immune system, cold

Allergic reaction

Numerous chemotherapy interactions


Cancer HIV AIDS Improves immunity

No significant toxicity reported

Numerous chemotherapy interactions

Evening primrose (Oenothera biennis)

Menopause Pain Neuropathy

Headache Nausea Risk of pregnancy complications

Binds proteins in serum (component of blood) and modifies effects of chemotherapy. Usage not recommended

Ginkgo tree (Ginkgo biloba)

Vomiting Antioxidant Dementia Tinnitus (ringing in ears)

Improves circulation

Bleeding Strokes Headaches Allergic reaction

Numerous chemotherapy interactions


Antidepressant Aphrodisiac Sedative Diuretic

Numerous, including: Euphoria Insomnia Headache Cardiovascular (hypotension, hypertension) Gastrointestinal (nausea, diarrhea) Vaginal bleeding

Numerous chemotherapy interactions ; avoid in ER+ breast and endometrial cancer

Green tea

Cancer prevention Prostate cancer Heart disease Gastrointestinal disease Weight loss

Nausea Diarrhea Insomnia Confusion

CYP450 interaction (liver enzymes responsible for metabolism of many drugs).

Increases effect of Anthracyclines, Taxane. Decreases effect of Bortezomib

Kava (stonecrop)

Anxiety Insomnia Stress

Numerous, including: Stupor Vision problems Dizziness Yellowing of skin and nails

Liver toxicities

Numerous chemotherapy interactions


Cancer Antiinflamatory Antiallergic Gastroprotective

High blood pressure Digoxin toxicity Hypokalemia Pulmanory edema

Numerous chemotherapy interactions

Milk thistle (Eryngium)

Fatty liver Cirrhosis Cancer prevention

Laxative effect


CYP450 (liver enzymes responsive for metabolism of many drugs). Decreased metabolism of Doxorubicin

Misletoe (Iscum album)

Cancer Stimulation of immune system Arthritis Sedation

Liver toxicity Anaphylactic shock

Numerous chemotherapy interactions


Improves immune system Diseases related to: Prostate Urinary system Arthritis Allergy Inflammatory conditions

Fever Bleeding Abdominal pain Diarrhea Hypoglycemia (low blood sugar) Galactorrhea (inapropriate milk production)

CYP450 (liver enzymes responsive for metabolism of many drugs)


Prostate cancer

Gynecomastia (development of breasts in men)

Decreased libido Gastrointestinal problems Heart problems Thrombus

Numerous chemotherapy interactions

Red grape seed

Allergic rhinitis Cancer prevention Hyperlipidemia (high blood lipid content)

No significant side effects reported

Numerous chemotherapy interactions

Reishi mushroom (red reishi)

Cancer Allergy Gastric ulcer Diabetes High blood pressure Hepatitis Nephritis Arthritis Bronchitis Insomnia Scleroderma

Bleeding Nausea Vomiting Liver toxicity

Numerous chemotherapy interactions

St. John's wort (Tipton's weed, Hypericum perforatum)


Numerous, including: Skin reaction Gastrointestinal disorder Dizziness Sleep problems Lack of energy

Numerous chemotherapy interactions

Valerian (Polemonium)

Stress Irregular sleep

Headache Restlessness Cardiac problems

Numerous chemotherapy interactions.

Be careful if you are using Tamoxifen, Cyclophosphomide, Etoposide, and Teniposide





Figure 2: Herbal therapies with no significant interaction reported. Modified from Arslan et al. (Arslan D, Tural D, Akar E. Herbal administration and interaction of cancer treatment. J Palliat Med. 2013;16(11):1466-1476. doi:10.1089/jpm.2013.0126.)





Chemotherapy Interaction

Bilberry (blueberry)

Diabetic retinopathy


Significant interaction not reported

Cranberry (blueberry, huckleberry)

Urinary tract infections


Significant interaction not reported


Nausea from chemotherapy

No significant side effects reported

Significant interaction not reported

Oleander (rosebay)

Cancer Heart failure HIV, AIDS Rheumatoid arthritis Psoriasis

Abdominal pain, Hypothermia Dizziness Respiratory paralysis Death

Significant interaction not reported

Saw palmetto (serenoa repens)

Benign prostatic hypertrophy

Gastrointestinal symptoms (nausea, vomiting, constipation, diarrhea, pain) Bleeding Embolism

Significant interaction not reported


Figure 3: Important non-chemotherapy interaction to be aware of.



Grapefruit Juice

Numerous uses

Significant interaction with CYP 450 system including:

immunosuppressants, some statins, benzodiazepines,

most calcium channel blockers, Indinavir and Carbamazepine. 5





1. Mainardi T, Kapoor S, Bielory L. Complementary and alternative medicine: Herbs, phytochemicals and vitamins and their immunologic effects. J Allergy Clin Immunol. 2009;123(2):283-294.e10. doi:10.1016/j.jaci.2008.12.023.

2. Guidance D. Guidance for Industry on Complementary and Alternative Medicine Products and Their Regulation by the Food and Drug Administration Guidance for Industry : Complementary and Alternative Medicine Products and Their Regulation by the Food and Drug Administrat. Heal (San Fr. 2006;(December).

3. Seely D, Stempak D, Baruchel S. A strategy for controlling potential interactions between natural health products and chemotherapy: a review in pediatric oncology. J Pediatr Hematol  Off J Am Soc Pediatr Hematol. 2007;29(1):32-47. doi:10.1097/MPH.0b013e3180310521.

4. Arslan D, Tural D, Akar E. Herbal administration and interaction of cancer treatment. J Palliat Med. 2013;16(11):1466-1476. doi:10.1089/jpm.2013.0126.

5. Grapefruit and drug interactions. Prescrire Int. 2012;21(133):294-5, 297-8.