The triad of chemotherapy induced over symptoms mucositis, xerostomia or dry mouth, and it disturbs sense of taste, should be considered as a single entity even when only one of these symptoms is present. While a large body of research has been published on the diagnosis and treatment of mucositis and xerostomia, the literature has all but ignored symptoms related to disturbances of taste, which are extremely prevalent among oncology patients, especially those being treated with platinum-based chemotherapy agents among others. Integrative oncology sees disturb taste as an important symptom reflecting the imbalances in the body's "energy" forces, and provides therapeutic options whose goal is to reduce unpleasant sensations while increasing pleasant ones. Herbal medicine plays a central role in treating this condition, with research indicating a beneficial effect of taste related sensations with the use of mixture containing sage, (salvia officinalis or salvia fruitcose mill), carob paste or syrup, and freshly squeezed wheatgrass juice. Wheatgrass juice is a popular treatment among oncology patients and can be purchased either as a liquid green juice or in a capsule form. Many patients grow wheatgrass at home, first soaking the seeds in water, and then planting them in a thin layer of soil. After about 10 days, the wheat seed sprouts are harvested and crashed into the green juice remedy, and then drunk by the patient usually in the early morning. Xerostomia or dry mouth may be relieved by eating bitter or sour foods such as lemon juice or lemon peel. In a study conducted in Iran, the hubs Alcea digitata and Malva sylvestris, were shown to alleviate dry mouth in patients with head and neck cancers who developed radiation induced xerostomia. As mentioned earlier, the use of a sage tea-thyme peppermint hydrosol all Ren's may also be of benefit in treating xerostomia in addition to its effect in reducing stomatitis. Other integrative oncology modalities can be of benefit as well for the treatment of xerostomia and should be considered for use in addition to the herbal remedies mentioned. These includes: Acupuncture, shown to be of benefit in patients with radiation induced xerostomia. Mind-body techniques, such as meditation, guided imagery, and hypnosis. Patients undergoing treatment modalities can be given a therapeutic suggestion in which they are asked to focus on a pleasant smell or taste, such as sweet lemon or a texture of food that they find enjoyable. Manual techniques such as the power method, may also be of benefit in treatment of xerostomia. This treatment focuses on the circular muscles such as those surrounding the mouth and the eye orbits. Nausea and vomiting, are common and often debilitating adverse effect of chemotherapy as well as other oncology treatment such as radiation. While conventional medications are extremely effective in reducing the onset and severity of these symptoms during the first days of treatment, they are more limited with respect to delayed masses, and are frequently accompanied by constipation and other adverse effects. In a previous section of this module, we discussed the use of herbal medicines for the treatment of chemotherapy induced nausea and vomiting. The most popular of which is ginger, zingiber officinale. However, before recommending that patients use herbs such as ginger for this indication, the following issues need to be considered; First, there is still debate in the medical literature as to the effectiveness of ginger, as well as the other integrative oncology therapies in relieving CINV. There are also a number of questions regarding the quantity and quality of the herbal products being sold over the counter. In an earlier session, we discussed the challenges faced in ensuring the consistent and reliable quantities of herbal medicinal products with many factors affecting what is actually in the final product. These include the mode of administration. In the case of ginger, whether the root is chewed, taken as a dry powder, or as a capsule, and so on. In addition, the effect of ginger may vary between patient genders and cancer types, with the herb found to be more effective in females and patients with head and neck cancer among others. Second point to consider is that while the research has shown that ginger can reduce symptoms such as nausea and the onset of vomiting following chemotherapy, it is unclear as to its effect on retching where the patient makes an effort to vomit without any Golgi dated material.The main effect of ginger, seem to occur during the 6-24 hour period after chemotherapy, and possibly delay emesis at 4-5 days post-treatment. The effectiveness of ginger in other oncology treatment settings has yet to be determined, and third point. Patients who are taking ginger to reduce CINV have also been found to report reduced fatigue and improved appetite, both of which may reflect the antiemetic effect of the herb, as well as themselves, factors which can increase the antiemetic effect of the herb. A number of ginger-based herbal formulas have been found to be effective in the relief of CINV. The Kampo or traditional Japanese herbal formula Rikkunshito, is comprised of eight herbs, which include Ginseng radix, Zizyphi fructus, Glycyrrhizae radix, ginger root and other herbs, and is prescribed for the treatment of anorexia and functional dyspepsia. This Kampo formula was found to reduce CINV and anorexia among patients with cervical and endometrial cancer who are being treated with Cisplatin and Paclitaxel. Other herbs, such as chamomile, have been found to be as effective as ginger in reducing CINV. Another traditional homemade remedy for treating CINV is a non-sweetened lemonade prepared with crushed whole lemons in water with bitter parts of the peel. We use medicines to prevent nausea and vomiting. This could be gentiana, this could be nux vomica, sometimes subcutaneously, sometimes just orally. As with other side effects of oncology treatments, it is important that patients be offered a variety of integrative oncology modalities for their CINV and not just herbal medicine. Integrative therapies such as acupuncture or acupressure have been studied extensively for the treatment of nausea and vomiting in both the oncology and post-operative setting. The most researched acupuncture point is Pericard-6, which is located between the flexor tendons of the forearm at a distance of two finger breadth, proximal to the anterior aspect of the wrist. In addition to providing relief of existing symptoms, Pericard-6 acupuncture has also been shown to prevent the onset of the leg CINV with an effect greater than that of conventional antiemetic drug Ondansetron Zofran. In children, the use of mind-body medicine especially hypnosis, has been shown to relieve existing and anticipatory CINV, as well as reducing anxiety. Oncology patients frequently suffer from disorders of the large bowel, which manifest as either constipation, diarrhea or an alternating state between the two. Certain chemotherapy agents such as the drug Irinotecan CPT-11 can cause severe diarrhea and the use of antiemetics and opioid analgesics for symptom control can cause constipation. A large body of research has been published on the effects of Chinese herbal remedies and formulas for the relief of constipation induced by chemotherapy and/or opioid drugs. These include Sheng Qi particles, Yi Qi Run Chang method, Bu-Zhong-Yi-Qi decoction and the others. Though most of the papers published in these remedies are in Chinese and have not been verified in large randomized and controlled trials. In addition to individual herbal products, the Chinese medicinal formula Xin Long Xe, was found to alleviate constipation and reduce anorexia in patients with metastatic gastric cancer. In another study, Chinese Ban Lan Gen Chong medicinal tea combined with the antiemetic agent Ondansetron, reduce constipation and abdominal distention in patients treated with taxon chemotherapy agents. The integrative oncology treatment program for treating constipation should include additional modalities and not rely solely on the use of herbal medicine. These should include electro-acupuncture, which has been shown to be of benefit with opioid-induced constipation. Wrist- ankle acupuncture combined with ginger moxibustion, which may both reduce nausea and relieve constipation. A self-treatment program with abdominal massage, abdominal muscle stretching and education on proper defecation positions, which has been shown to significantly alleviate constipation in patients with antiemetic-induced constipation during chemotherapy for breast cancer. Aromatherapy massage shown to be of benefit in patients with advanced cancer suffering from severe constipation. In addition to their effects on relieving constipation, a number of herbal remedies have been shown to reduce chemotherapy-induced diarrhea as well. These include the use of Japanese Kampo remedies for the prevention of irinotecan-induced diarrhea in patients with advanced non-small cell lung cancer. Additional integrative oncology modalities to consider for the treatment of chemotherapy-induced diarrhea include the following. The use of an omega-3 fatty acid-containing supplement, which was shown to reduce diarrhea, as well as stomatitis in patients undergoing neoadjuvant chemotherapy for esophageal cancer. The use of probiotics shown to help reduce diarrhea in patients with colorectal cancer undergoing an irinotecan-based chemotherapy regimen.
