SIO Integrative Tumor Board: SIO Integrative Tumor Board Donald I. Abrams, MD - Moderator Jnani Chapman, RN, BSN, CMT, CYT Anand Dhruva, MD Weidong Lu, MB, MPH, Lac Beverly Pierce, MLS, MA, RN, CHTP Martin L. Rossman, MD, Dipl Ac (NCCA) Leanna J. Standish, ND, PhD, Dipl Ac


Stage IIA Breast CA on Chemo: Stage IIA Breast CA on Chemo 44 yo woman who noted L breast lump one year ago. Long hx of “lumpy breasts” during menses. UTZ 2 mos later: negative. Mammography 5 mos later: negative 5 mos ago noted L AX swelling. Underwent lumpectomy an L AX lymph node dissection 1.5cm infiltrating ductal carcinoma, + margin ER+/PR+/her 2 negative 2/11 lymph nodes positive Margin still + after re-excision


Stage IIA Breast CA on Chemo: Stage IIA Breast CA on Chemo Currently s/p AC with two more doses paclitaxel; then re-excision and radiation Comes for integrative options PMH: HTN, Fe-def anemia ? Due to menses FH/SH: Parents alive; 4 sibs (2 sisters) – no breast CA; niece with breast CA. Pt sans children. Engineering degree and MBA. She and husband work with start-up companies. Raised Catholic but not practicing


Stage IIA Breast CA on Chemo: Stage IIA Breast CA on Chemo Diet: meat, dairy; no sugar or refined grains Activity: Horseback riding and aerobics; concerned about lymphedema Rx: Nifedipine, metoprolol, iron, lorazepam prn MVI, folate, Vit B6, C, E Glutamine, lysine, fish oil, glucosamine Co-Q 10, melatonin, Chinese herbs Stops supplements while receiving chemotherapy Prior CAM experience: chiropractor, massage and TCM practitioner weekly


Stage IIA Breast CA on Chemo: Stage IIA Breast CA on Chemo O/E Thin pleasant woman in NAD Well-healed LUOQ and axillary scars Tongue with mild yellow coating Right anterior chest port No lymphadenopathy Abdomen: benign Your Recommendations?


Stage IV Prostate Cancer: Stage IV Prostate Cancer 69 year old gentleman who developed urinary symptoms in 1992 TURP in 2002 Urinary sx recurred in 8/05; PSA-49 Found to have T3 node positive Gleason 4+5 adenocarcinoma Began bicalutamide and depot leuprolide; lost libido and erectile function Dx exacerbated depression; received ECT


Stage IV Prostate Cancer: Stage IV Prostate Cancer Plan 7 weeks of radiation; advised not to take antioxidants during XRT Comes for nutritional and other support PMH: Chronic depression s/p ECT, on increased meds with no relief; “morbidly obsessed” with his prostate cancer dx. 25 pack/yrs, quit ’86, now pipe. Rare alcohol. FH/SH: Born Iraq; Bay Area since 1960. Married 41 years. 2 children Heating equipment manufacturer rep. Raised Catholic; currently “without religious conviction”


Stage IV Prostate Cancer: Stage IV Prostate Cancer Diet: Cereal, walnuts, cranberries; eggs or meat sandwich; dinner “varies” Activity: walking, cycling, sailing in past Rx: Leuprolide, bicalutamide, terazosin, finasteride Valproate 250 mg bid, fluvoxamine 100 mg, olanzapine 15 mg, clonazepam 1.5 mg Supplements: None Prior CAM experience: None


Stage IV Prostate Cancer: Stage IV Prostate Cancer O/E: Elderly gentleman with flat affect; appears depressed Poor dentition; tongue with yellow-brown coat Lymph nodes: none Chest: Decreased breath sounds Abdomen: no masses or organomegaly MS: No boney tenderness Your Recommendations?


Unresectable Pancreatic Cancer : Unresectable Pancreatic Cancer 65 y.o. gentleman with neg PMH, developed trouble digesting food 2 yrs ago Upon losing weight, CT ordered, + for pancreated mass Aborted Whipple in 2/05 because of vascular issues; gastric bypass and removal of necrotic tissue performed Post-op radiation and gemcitabine; tumor now “stunned”, next CT in 3 mos


Unresectable Pancreatic Cancer: Unresectable Pancreatic Cancer Comes b/o weight loss from 200 to 145 and total body sense of “malaise or unwellness” that responds to hydrocodone/APAP and lorazepam PMH: neg ROS: Low back pain SH/FH: Born PA; here x 15 years. Bro and 2 sisters on East Coast. Married 39 yrs; 2 daughters, 1 son. Was teacher, then DEA agent; wife college prof; “haphazard Catholics” although he does attend regularly and has a strong belief system


Unresectable Pancreatic Cancer: Unresectable Pancreatic Cancer Diet: cereal, fruit; sandwich, fruit, yoghurt; fish, vegetable, starch, salad Activity: None because of fear of burning calories Rx Lipase/Protease/Amylase, nateglinide Hydrocodone/APAP 1 q 4hrs, lorazepam qHs Supplements: None Prior CAM Experience: Nutritionist


Unresectable Pancreatic Cancer: Unresectable Pancreatic Cancer O/E: Thin elderly gentleman lying on exam table Skin: seb k’s and cherry angiomata Tongue red without coating Decreased breath sounds at bases Scaphoid abdomen, hyperactive bowel sounds, healed midline scar, non-tender, without masses Your Recommendations?


Resected Non-Small Cell Lung CA: Resected Non-Small Cell Lung CA 57 y.o. woman with abnl CXR pre-op for hip replacement, felt pneumonia related Ultimately work-up revealed LUL NSCCA Received neoadjuvant carboplatin/paclitaxel Underwent LULobectomy 14 wks ago; IA Told she is cured with low likelihood of recurrence, but friend with breast CA told same and recently died with brain mets


Resected Non-Small Cell Lung CA: Resected Non-Small Cell Lung CA Comes for info on “how to live a long and happy life”. Also concerned by persistent post-op pain Feels as if “ a shovel or meat cleaver is stuck” Feels “disconnected from my body”, “this isn’t part of me anymore” PMH: Congenital hip; 40 pack years; quit 9 months prior to dx; HTN; gained 15# on chemo SH/FH: Born Detroit, eldest of 5. Elderly unwell parents in No. Cal. Obese retired husband. No kids. Pt retired insurance executive. No religion or spiritual belief system


Resected Non-Small Cell Lung CA: Resected Non-Small Cell Lung CA Diet: Western; drinks wine Activity: Trying to exercise; limited by pain Rx: Gabapentin 300 mg tid; ibuprofen; aspirin Atenolol 50 mg, lisinopril 20 mg Pantoprazole MVI, Vit D 1000 IU, Vit E 400 IU, Ca- 1000 mg, selenium 200 mcg Prior CAM Experience: Guided imagery, hypnosis, meditation, Reiki, massage, yoga


Resected Non-Small Cell Lung CA: Resected Non-Small Cell Lung CA WD, WN woman with some pain on changing posture Wears a wig despite scalp hair regrowing Tongue without coat Chest: healed L thoracotomy scar and drain sites Slightly labile, tearful about her fear of recurrence, loss of friends, aging parents Your Recommendations?


Low Grade Lymphoma : Low Grade Lymphoma 67 y.o. woman with low grade NHL (follicular vs marginal) dx’ed 9/00 on R submandibular biopsy PET with diffuse LAN; marrow suggestive Pt has chosen watchful waiting and is cared for by TCM practitioner who has cared for husband with prostate CA for 8 yrs, recently recurred Daughter-in-law recently dx with GBM, only will accept conventional treatment


Low Grade Lymphoma: Low Grade Lymphoma Comes for opinion re: commencing rituximab PMH: Hypercholesterolemia on no meds; upper back issues uses Feldenkreis, recent weight gain secondary to stresses SH/FH: Born Detroit. Only child. Father died 53 abuse of EtOH, tobacco, mother 92 with colon CA; married 37 years to second husband; 5 kids, 2 biological; culturally Jewish, but spirituality based in nature


Low Grade Lymphoma: Low Grade Lymphoma Diet: Soy milk shake; whole wheat toast, nuts; salad, sandwich, soup; fish, salad, green vegetable, starch; cookies, chocolate, fruit Activity: Gardening, stretching, Tai chi Rx: Alendronate sodium Rotating Chinese herbs; Cordyceps sinensis Folic acid, Vit D3 1000 IU, Ca Co-Q 10, alpha-lipoic acid, green tea extract, fish oil Prior CAM Experience: TCM, meditation, Tai chi


Low Grade Lymphoma: Low Grade Lymphoma O/E: Overweight woman in NAD Skin: mildly diaphoretic Nodes: 5 cm R cervical mass, BL 2 cm AX Chest: clear Abd: no organomegaly or masses Your Recommendations?


Metastatic Colon Cancer: Metastatic Colon Cancer 67 yo gentleman with hx obesity to 300 lbs, DM, HTN and elevated cholesterol Hospitalized one year ago with crampy abdominal pain; CT with liver lesions,↑ CEA Colonoscopy revealed a cecal adenoCA Began FOLFOX/bevacizumab; took break for daughter’s wedding Responded to but felt “knocked out” Now on FOLFIRI/bevacizumab for ↑ CEA, LFTs


Metastatic Colon Cancer: Metastatic Colon Cancer Comes seeking advice on how to eliminate side effects of chemo and to increase quality and quantity of remaining life PMH: As above. Heavy EtOH and tobacco in past. ROS: diarrhea, painful mucositis, febrile neutropenia, wt ↓ to 225 FH/SH: Born SF. Married 36 yrs. One son, one daughter. Chemical engineer. No religious affiliation but believes in God.


Metastatic Colon Cancer: Metastatic Colon Cancer Diet: Mainly pureed foods currently b/o oral pain; heavy dairy Activity: None Rx: FOLFIRI and bevacizumab Metformin 850 mg tid, glipizide 10 mg bid Lisinopril 10 mg qd, gemfibrizol 600 mg bid Rosaglitizone 8mg qd Lorazepam, hydrocodone/APAP, prochloperazine, zolpidem, diphenoxylate/atropine, docusate, senna, EPO, G-CSF, mouth rinses all prn Prior CAM Experience: Multivitamins, now stopped


Metastatic Colon Cancer: Metastatic Colon Cancer O/E: Obese, elderly gentleman in NAD Ulceration R third finger Conjunctival pallor; fair dentition; angular cheilitis; no frank mucositis visible Chest: occ. Expiratory wheeze Cor: tachycardia Abd: obese with ventral herniation; healed midline scar, no organomegaly, masses Your Recommendations?


Astrocytoma and Myopathy: Astrocytoma and Myopathy 56 y.o. R-handed gentleman found to have R temperoparietal mass following a seizure 8 months ago Path at craniotomy was anaplastic astrocytoma Gr. III Underwent 6 wks of radiation with temozolamide with good tumor response but edema requiring dexamethasone Steroids caused weight gain, moon facies, edema and severe proximal myopathy esp Les When he attempts to taper steroids, edema flares with motor weakness, falls and focal motor seizures


Astrocytoma and Myopathy: Astrocytoma and Myopathy Comes to discuss QOL and symptom mx PMH: Elevated cholesterol; no tobacco; 1-3 glasses red wine/day in past; ROS: as above; weight gain from 190 to 205; constipation on temozolamide FH/SH: Born NYC. Only child. Parents deceased. Bay Area since ’89. Married 25 yrs; former newspaper photographer; now tech consultant; raised Catholic but now he and wife both active in Episcopalian congregation; wife appears upset with husband’s disabilities


Astrocytoma and Myopathy: Astrocytoma and Myopathy Diet: Fruit, yoghurt; salad, chicken; fish, beef or pork, green vegies, salad, peanuts Activity: Currently unable b/o symtoms; very physically active in past as is wife now Rx: Temozolamide 5 days on, 3 weeks off; laxative prn Dexamethasone taper as able, now 10 mg Levetiracetam 150 mg bid, pregabalin 400 mg qd Omacor Multivitamin, calcium Prior CAM Experience: None


Astrocytoma and Myopathy: Astrocytoma and Myopathy O/E: Slightly cushingoid, walks with cane, L-sided weakness Moon facies, no thrush Abd: obese sans organomegaly, masses Ext: 2-3+ bipedal edema; proximal muscle weakness L>R CNS: Articulate, frustrated, mild L paresis Your Recommendations