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Evidence-based Breast Cancer Treatment Guidance - The State of the Art
Compiled by: Constantine Kaniklidis, medical researcher,
member, European Association for Cancer Research (EACR)
[ Breast Cancer Watch is a member of the Evidencewatch portal of evidence-based medicine sites ]


Breast Cancer Watch is a unique service providing the latest best evidence-based guidance on state-of-the-art breast cancer therapies, annotated with critical commentaries, and clinical practice recommendations. Critical appraisal and systematic review is undertaken aggressively with major updates monthly, and at least weekly revisions for high-impact findings. The series addresses two problems: (1) the lack of any timely single-source evidence-based systematic review of breast cancer treatment research findings for both healthcare professionals and informed patients, and (2) the rapid aging of breast cancer guidelines issued on less timely schedules (e.g., NCCN, ASCO and other guidelines).      [updated: 4/10/09]



Drug Interactions in Oncology


  • Patient Corner: Drug Interactions
    Note that in the world of the (hepatic) Cytochrome P450 system a substrate is a CYP enzyme (technically, isoenzyme) that simply performs a reaction on a medication, an inhibitor is an agent binding so strongly to a CYP enzyme that it prevents the enzyme from metabolizing other medications, while an inducer is an agent that interacts with the enzyme to cause new production of the enzyme.  Thus, an inhibitor of a specific CYP isozyme may decrease the metabolism of the drug and hence increase serum concentrations - and toxicity - of drugs that are substrates for that isoenzyme, while an inducer of a specific CYP isozyme may increase the metabolism of the drug and decrease serum concentrations - and efficacy - of drugs that are substrates for that isozyme.

    Anthracyclines and taxanes, as well as the aromatase inhibitor exemestane (Aromasin) and the vinca alkaloid vinorelbine (Navelbine) are predominantly metabolized by the CYP3A4 enzyme, and so we say they are CYP3A4-mediated.  And many other agents are either CYP3A4-inducers and CYP3A4-inhibitors. An inhibitor will increase the concentration of another agent it's given with (because it inhibits its clearance, and so allows the agent to remain in the system longer than required, increasing toxicity), while an inducer will decrease the concentration of another agent it's given with (because it enhances its clearance, and so allows the agent to remain in the system less time than required, decreasing efficacy). Grapefruit juice is a CYP3A4-inhibitor, and so if consumed with most chemotherapies, will dangerously increase the toxicity of the chemotherapy agent, with hazardous adverse effects and morbidities, and some documented fatalities. Many natural agents are CYP3A4 inducers or inhibitors and therefore, like grapefruit juice, can either increase the toxicity, or reduce the efficacy, of several chemotherapy agents I noted above, and of the AI Aromasin, and these include St. John's Wort, goldenseal, chamomile, sage and licorice teas, and the oils of Evening Primrose and Borage, among others, and so it is prudent to avoid co-consumption during oncotherapy with the agents I noted which are CYP3A4-mediated in their metabolism. Certain statins can also interfere with these same chemotherapy agents, and with the aromatase inhibitor (AI) exemestane (Aromasin). Another example of adverse interaction concerns tamoxifen metabolism: tamoxifen is predominantly CYP2D6-mediated, and St. John's Wort and all SSRI type antidepressants can interact across the CYP2D6-mediated enzyme to render tamoxifen to near-placebo levels, with obvious and dire consequences, and the clinical relevance, not just in vitro and in vivo, of this was been well established. The clinical lesson is that extreme caution needs to be exercised to assure that coadministration of agents jointly metabolized across the same cytochrome p450 system enzyme not induce adverse interactions. Avoiding inadvertent compromise of the efficacy and/or safety of the broad spectrum of oncotherapies is exceedingly difficult, and there is therefore unfortunately bound to be a large body of patients whose oncotherapy efficacy may have been compromised not by being refractory to it, or resistant, but rather by then-unknown adverse agent interactions.


    • Issues in Tamoxifen Metabolism
    Tamoxifen is converted into its active metabolites 4-hydroxy-tamoxifen, endoxifen, and other active metabolites, in the liver by the CYP2D6 liver enzyme, one of many CYP enzymes that are part of the liver's P450 detoxification pathway (aka the hepatic cytochrome P450 enzyme system), and primarily responsible for the metabolism of tamoxifen into its active metabolites (plasma concentrations of these active metabolites are associated with the cytochrome P450 (CYP) 2D6 genotype). We now know that the efficacy of tamoxifen therapy for the treatment of breast cancer exhibits wide individual variation among individuals that appears to be genetic, with some women able to convert tamoxifen into active metabolites more effectively than others; women with the normal gene produce somewhere in the order of two to four times as much of active metabolites as those with with the variant that is a relatively ineffective tamoxifen active metabolite converter.

    Tamoxifen and SSRI Antidepressants
    Working from the fact that SSRI ( selective serotonin reuptake inhibitor) antidepressants are known to be CYP2D6 enzyme inhibitors, Stearns and colleagues (J Natl Cancer Inst (2003): Active Tamoxifen Metabolite Plasma Concentrations After Coadministration of Tamoxifen and the Selective Serotonin Reuptake Inhibitor Paroxetine) identified a previously unrecognized active metabolite of tamoxifen, endoxifen, and found that endoxifen was present in substantially higher concentrations than 4-hydroxy-tamoxifen, but after administration of the SSRI antidepressant paroxetine (Paxil) treatment, endoxifen levels decreased, but levels of 4-hydroxy-tamoxifen did not. At that time, the researchers suggested that CYP2D6 genotype and drug interactions should be considered in women treated with tamoxifen; however, the precise clinical implications of low circulating endoxifen concentrations were not fully known (Goetz et al., J Natl Cancer Inst (2003): A Hot Flash on Tamoxifen Metabolism).

    Some of the same researchers (Stearns et al., J Clin Oncol (2004): The effect of CYP 2D6 genotype and CYP2D6 inhibitors on tamoxifen) have revisited this problem, reporting preliminary data from an ongoing prospective study to confirm the original findings. The later study found that certain CYP 2D6 genotypes, as well as the use of the CYP 2D6 inhibitor SSRI antidepressants sertraline and paroxetine strongly influence tamoxifen conversion to endoxifen. However Breast Cancer Watch notes that although endoxifen levels were affected adversely, there was no change in concentrations of tamoxifen itself or its other metabolites, thus still leaving unclear the clinical implications of these results (the authors concluded that therefore the findings are still insufficiently powered to dictate any change to prescribing practices at that time).

    Breast Cancer Watch further notes that although the SSRIS sertraline (Zoloft) and paroxetine (Paxil) as CYP2D6 inhibitors were associated with low concentrations of endoxifen, the dual mechanism agent venlafaxine (Effexor), a serotonin/norepinephrine reuptake inhibitor (SNRI), was not, suggesting that the SNRI venlafaxine (Effexor) in particular may be a potential workaround for breast cancer patients requiring hot flash relief (although we note that gabapentin is also an effective alternative choice; see below our discussion of neuroactive agents). Some confirming evidence of this advantage for venlafaxine was recently put forward by Jin et al. in their prospective observational study (J Natl Cancer Inst (2005): CYP2D6 Genotype, Antidepressant Use, and Tamoxifen Metabolism During Adjuvant Breast Cancer Treatment) which found that plasma endoxifen concentration was only slightly decreased by venlafaxine, a weak inhibitor of CYP2D6, but substantially reduced in subjects who took paroxetine (Paxil), a potent inhibitor of CYP2D6), with again the magnitude of the reduction in plasma endoxifen concentration associated with CYP2D6 inhibitor use dependent on the CYP2D6 genotype. The researchers however prudently note that although SSRIs may affect tamoxifen’s antitumoral efficacy or its side effects, this hypothesis requires further testing in actual clinical trials.

    Tamoxifen and Non-SSRI Antidepressants
    Although therefore the SNRI venlafaxine (Effexor) is a weak CYP2D6 inhibitor, the two other SNRIs mirtazapine (Remeron) and duloxetine (Cymbalta) both appear to have significant potential interaction across CYP2D6 and hence may raise similar adverse interaction potential. 

    A systematic review of the literature, as of April 2008, for potentially adverse significant interactions between tamoxifen CYP2D6 metabolism and any antidepressant including SSRIs, SNRIs, tricyclics (TCAs), and various atypicals such as bupropion (Wellbutrin), nefazodone (Serzone), among others, has failed to uncover decisive evidence of any wholly unproblematic antidepressant outside of what is already known solely on venlafaxine (Effexor), and the just FDA-approved venlafaxine analog, desvenlafaxine (Pristiq). However, there are some qualifications to be noted here: 

    (1) Mirtazapine (Remeron)     at pharmacological concentrations can moderately increase the activity of CYP2D in hepatocytes, with the CYP2D2 isoform being the principle contributor to this effect (Haduch A, Bromek E, Kot M, et al. Effect of mirtazapine on the CYP2D activity in the primary culture of rat hepatocytes. Pharmacol Rep. 2006 Nov-Dec;58(6):979-84. [pdf]), and the available in vitro and in vivo data suggest that mirtazapine is unlikely to affect the metabolism CYP2D6- metabolized drugs (Holm K, Markham A. Mirtazapine: a review of its use in major depression. Drugs 1999;57:607-31), and  this having been cross-confirmed and extended to include improbable inhibition of CYP1A2 and CYP3A4 also (Kasper S, Praschak-Rieder N, Tauscher J, Wolf R. A risk-benefit assessment of mirtazapine in the treatment of depression. Drug Saf 1997;17:251-64). However, there are apparently some discordant findings on CYP2D6: German researchers have found in a small human study that the clearance of CYP2D6 intermediate metabolizers was reduced by 26% compared with that of extensive metabolizers, but we note that this magnitude of decrement is unlikely to be appreciably above borderline clinical significance (Grasmäder K, Verwohlt PL, Kühn KU, et al. Population pharmacokinetic analysis of mirtazapine. Eur J Clin Pharmacol. 2004 Sep;60(7):473-80). Finally, we should note that the official mirtazapine (Remeron) labeling bares the following warning:

    "    In vitro studies have shown that mirtazapine is a substrate for several of these enzymes, including 2D6, 1A2, and 3A4. While in vitro studies have shown that mirtazapine is not a potent inhibitor of any of these enzymes, an indication that mirtazapine is not likely to have a clinically significant inhibitory effect on the metabolism of other drugs that are substrates for these cytochrome P450 enzymes, the concomitant use of REMERON® with most other drugs metabolized by these enzymes has not been formally studied. Consequently, it is not possible to make any definitive statements about the risks of coadministration of REMERON® with such drugs"

    which we note is in agreement with the conclusions stated by Leon Delbressine and Ria Vos with Organon: "    the contribution of its [mirtazapine] metabolites to the pharmacologic effect is negligible"; "it has no inducing or inhibiting effects on the hepatic P450 enzymes"; "it has a very low potential for clinically relevant pharmacokinetic interactions with other drugs; and its disposition is independent of polymorphic CYP2D6 activity" (Delbressine LP, Vos RM. The clinical relevance of preclinical data: mirtazapine, a model compound. J Clin Psychopharmacol. 1997 Apr;17 Suppl 1:29S-33S). 

    (2) As for the atypical antidepressant bupropion (Wellbutrin), in vitro research has shown that it is primarily metabolized to its major metabolite hydroxybupropion by the CYP2B6 isoenzyme (Kirchheiner J, Klein C, Meineke I, et al. Bupropion and 4-OH-bupropion pharmacokinetics in relation to genetic polymorphisms in CYP2B6. Pharmacogenetics. 2003 Oct;13(10):619-26), and this suggests caution in coadministration with CYP2B6 substrates such as cyclophosphamide (Cytoxan) which is both a CYP2B6 and CYP2C19 substrate (Ekhart C, Doodeman VD, Rodenhuis S, et al. Influence of polymorphisms of drug metabolizing enzymes (CYP2B6, CYP2C9, CYP2C19, CYP3A4, CYP3A5, GSTA1, GSTP1, ALDH1A1 and ALDH3A1) on the pharmacokinetics of cyclophosphamide and 4-hydroxycyclophosphamide. Pharmacogenet Genomics 2008 Jun; 18(6):515-523) and accordingly bupropion (Wellbutrin) bears a label warning to this effect, with some caution required also if coadministered with promethazine (Phenergan), among many other CYP2B6 substrates.

    And although we note that this is the only CYP enzyme (CYP2B6) noted as a label warning, it appears that there may also be some significant CYP2D6-mediated interactions (Kotlyar M, Brauer LH, Tracy TS, et al. Inhibition of CYP2D6 activity by bupropion. J Clin Psychopharmacol. 2005 Jun;25(3):226-9; Güzey C, Norström A, Spigset O. Change from the CYP2D6 extensive metabolizer to the poor metabolizer phenotype during treatment With bupropion. Ther Drug Monit. 2002 Jun;24(3):436-7).  On the one  hand, bupropion     product labeling indicates that CYP2D6 is inhibited by bupropion or hydroxybupropion, and on the other the study of Leah Hesse at Tufts and her colleagues (Hesse LM, Venkatakrishnan K, Court MH, et al. CYP2B6 mediates the in vitro hydroxylation of bupropion: potential drug interactions with other antidepressants. Drug Metab Dispos 2000 Oct; 28(10):1176-83) suggests that at the in vitro level bupropion and hydroxybupropion have relatively low CYP2D6 inhibitory potential, concluding that "bupropion does not inhibit CYP2D6 in vivo and that bupropion itself is not likely to be a substrate for CYP2D6", while on the other we have human volunteer studies such as that of Michael Kotlyar and colleagues (see above) which has suggested a greater potency, at a level of clinically significant adverse interactions and whose study concluded that "Bupropion is therefore a potent inhibitor of CYP2D6 activity, and care should be exercised when initiating or discontinuing bupropion use in patients taking drugs metabolized by CYP2D6". Nonetheless, despite these dissonant findings, the balance of the evidence suggests that bupropion inhibits CYP2D6 and hence may reduce clearance of CYP2D6-metabolized agents, and we consider recent studies as confirmatory of this conclusion, including James Jefferson at the University of Wisconsin and colleagues (Jefferson JW, Pradko JF, Muir KT. Bupropion for major depressive disorder: Pharmacokinetic and formulation considerations. Clin Ther 2005 Nov; 27(11):1685-95) and the recent findings of the GSK team of Melissa Reese and colleagues (Reese MJ, Wurm RM, Muir K, et al. An in Vitro Mechanistic Study to Elucidate the Desipramine / Bupropion Clinical Drug-Drug Interaction. Drug Metab Dispos 2008 Apr 17) who concluded that the "reductive metabolites of bupropion are potent competitive CYP2D6 inhibitors in vivo", and coupled with the human clinical cases cited above, the CYP2D6-inhibitory activity of bupropion (Wellbutrin, Zyban) should be assumed to carry at least a non-trivial potential for significant adverse interactions in humans when coadministered CYP2D6-metabolized agents.     

    Other Issues
    More recently still Hiltrud Brauch and colleagues with the German AGO TRAFO Commission further confirmed that recent mechanistic, pharmacologic, and clinical pharmacogenetic evidence suggests that genetic variants and drug interaction by CYP2D6 inhibitors, with CYP2D6 being the key enzyme in tamoxifen biotransformation into the clinically relevant metabolites, 4-OH-tamoxifen and endoxifen, influence plasma concentrations of active tamoxifen metabolites and consequently outcome of the patients treated with adjuvant tamoxifen, with non-functional (poor metabolizer) and severely impaired (intermediate metabolizer) CYP2D6 variants being associated with higher recurrence rates (Brauch H, Schroth W, Eichelbaum M, Schwab M, Harbeck N, in cooperation with the AGO TRAFO Commission: Clinical Relevance of CYP2D6 Genetics for Tamoxifen Response in Breast Cancer. Breast Care. 2008;3:43-50). This suggests (1) that strong CYP2D6 inhibitors such as SSRI antidepressants should be avoided as co-medication, and (2) that there is an important role for pre-treatment CYP2D6 genotyping to predict of metabolizer status and hence outcome, enabling individualization of endocrine treatment choice and benefit. 

    In addition, as we note elsewhere in this review, although tamoxifen metabolism is primarily CYP2D6-mediated, there is still a partial non-trivial CYP3A4 dependency.  In this connection, William Chi at Princess Margaret Hospital and colleagues (Chu W, Fyles A, Sellers EM, et al. Association between CYP3A4 genotype and risk of endometrial cancer following tamoxifen use. Carcinogenesis. 2007 Oct;28(10):2139-42) have found that a genetic variant of the CYP3A4 gene, CYP3A4*1B, influences endometrial cancer risk: women carrying the CYP3A4*1B allele who had 3-fold increase in the risk of developing endometrial cancer from tamoxifen treatment compared with women not on tamoxifen, suggesting that a subgroup of breast cancer patients - namely, CYP3A4*1B allele carriers on tamoxifen - may be at increased risk of developing endometrial cancer.

    Breast Cancer Watch Guideline:
    Hot Flash Relief in Breast Cancer Patients
    Based on the above findings, we suggest that the evidence supports a first-line trial of gabapentin (Neurontin) 900mg./day, followed by a trial of low-dose (37.5 mg/day) venlafaxine (Effexor) or extended-release venlafaxine at 75mg./day) if patient fails to achieve sufficient relief on gabapentin.

    Aromatase Inhibitor (AI) Interactions

    As to the aromatase inhibitors (AIs), there is the potential for drug-drug or drug-herb interactions for all three aromatase inhibitors (AIs), but to significantly different degrees, if there is concomitant medication that interacts with certain cytochrome P450 enzymes.

    Therefore breast cancer patients undergoing therapy with:

    • Taxanes:
      Docetaxel (Taxotere)      , Paclitaxel (Taxol)), Nab-paclitaxel (Abraxane))
      Note that the paclitaxel-based taxanes - paclitaxel (Taxol) and nab-paclitaxel (Abraxane) - exhibit first-pass extraction by cytochrome P450-dependent metabolic processes, with the CYP2C8 isoenzymes metabolizing paclitaxel to the major metabolite 6-hydroxypaclitaxel the M5 metabolite), and CYP3A4 metabolizing paclitaxel to 3-hydroxypaclitaxel, a minor metabolite (the M4 metabolite). [Scripture CD, Figg WD, Sparreboom A. Paclitaxel chemotherapy: from empiricism to a mechanism-based formulation strategy. Ther Clin Risk Manag. 2005 Jun;1(2):107-14; Cresteil T, Monsarrat B, Dubois J, Sonnier M, Alvinerie P, Gueritte F. Regioselective metabolism of taxoids by human CYP3A4 and 2C8: structure-activity relationship. Drug Metab Dispos. 2002 Apr;30(4):438-45; Cresteil T, Monsarrat B, Alvinerie P, Tréluyer JM, Vieira I, Wright M. Taxol metabolism by human liver microsomes: identification of cytochrome P450 isozymes involved in its biotransformation. Cancer Res. 1994 Jan 15;54(2):386-92; full text (pdf)].  
    • Vinca alkaloids (vinorelbine (Navelbine), vinblastine (Velban), vincristine (Oncovin)),
    • Aromatase inhibitor exemestane (Aromasin)
    • Tamoxifen (mainly CYP2D6-mediated, but potential CYP3A-mediation in addition)
    • The biological anti-VEGF / antiangiogenic agent bevacizumab (Avastin) undergoes complex biotransformation by different enzymatic routes which includes CYP3A4 (which is reversibly inhibited by bevacizumab (Avastin) and other monoclonal antibodies (MoAbs)). [Schueller J, Czejka M, Kiss A, Krexner E, Aigner K, Wirth M. Influence of bevacizumab on the plasma disposition of CPT 11 and its metabolites in advanced colorectal cancer patients. ASCO Meeting Abstracts Jun 20 2006: 3540].
    • The biological dual-TKI lapatinib (Tykerb) is a substrate of CYP3A4, CYP3A5 and CYP2D19 [Zaks TZ, Akkari A, Briley L, et al. Role of pharmacogenetic studies in early clinical development: Phase I studies with lapatinib.2006 ASCO Annual Meeting Proceedings (Post-Meeting Edition). Vol 24, No 18S (June 20 Supplement), 2006: 3029]. Since lapatinib (Tykerb) is extensively metabolized by cytochrome P450 isoenzyme CYP3A4, concomitant use of strong CYP3A4 inhibitors (including grapefruit juice) can increase lapatinib plasma concentrations and may induced untoward toxicity. If it is necessary to coadminister a strong CYP3A4 inhibitor, pharmacokinetic study data suggest that a dosage reduction to 500 mg/day of lapatinib may adjust AUC (area under the curve) to an appropriate range, and it should be noted that if a strong CYP3A4 inhibitor is discontinued, the FDA advises a washout period of approximately 1 week prior to adjusting the lapatinib dose upwards. In contrast, concomitant use of strong a CYP3A4 inducer (like dexamethasone, carbamazepine, or St. John's Wort, among many others) should be avoided because of the consequent decrease in lapatinib plasma levels. In this case, if coadministration of a strong CYP3A4 inducer is required, lapatinib dosing should be gradually titrated from 1250 to 4500 mg/day based on tolerability, with normal dosing of lapatinib resumed after discontinuation of the CYP3A4 inducer.[See Moy B, Goss PE. Lapatinib-associated toxicity and practical management recommendations. Oncologist. 2007 Jul;12(7):756-65; also: FDA CDER Highlights of Prescribing Information - Lapatinib (Tykerb) [pdf].  

    should be cautioned to avoid concurrent use of these CYP3A4-mediated agents:

    • goldenseal and chamomile extracts and teas,
    • St. John's Wort,
    • spices sage, thyme and cloves,
    • soybean components daidzein and genistein,
    • grapefruit juice (via its active component pergamottin),
    • licorice extracts and teas (via its glabridin active component), and
    • possibly Serenoa repens (Saw palmetto)
    • also possible: EPO (Evening Primrose Oil) / Borage (seed) Oil, across CYP3A4

    to avoid potential and significant modification of the antitumor activity / efficacy, and/or toxicity, of these chemotherapeutic agents.


    Black Cohosh
    The black cohosh extracts can potentially (1) increase the cytotoxicity of doxorubicin and docetaxel and (2) decrease the cytotoxicity of cisplatin, radiation and 4-hydroperoxycyclophosphamide (4-HC), an analog of cyclophosphamide (see the animal study of Rockwell et al., Breast Cancer Res Treat (2005): Alteration of the effects of cancer therapy agents on breast cancer cells by the herbal medicine black cohosh).

    In addition, black cohosh has been found to be a potent CYP3A4 inhibitor in vitro (Tsukamato et al., Evid Based Complement Alternat Med (2005): Isolation of CYP3A4 Inhibitors from the Black Cohosh (Cimicifuga racemosa)), and this has some grave implications for cancer therapies, given clinical risks associated with changes in either the bioavailability or the metabolic rate of clinically administered drugs. Over 50% of clinically used drugs are oxidized by CYP3A4, which is part of the family of cytochrome P450 (CYP) enzymes responsible for drug metabolism, carcinogenesis (process by which normal cells are transformed into cancer cells) and degradation of xenobiotics (substances foreign to the biological system). However in our critical appraisal of this study Breast Cancer Watch notes that this study appears to have used an excessively high dosage of 40 mg of the herbal extract itself, not 40 mg of the herbal drug, the latter being the standard formulation of the Remifemin black cohosh product (see the commentary of Beat Meier, Evid Based Compliment Alternat Med (2005): No characterisation of the extract and questionable in-vivo correlation), and given this, the methodological legitimacy of the conclusions of the widely-cited Tsukamato study are undermined. Indeed, as we will demonstrate below, human clinical data (Bill Gurley, cited below) has found that black cohosh appears to have no clinically relevant effect on CYP3A activity.

    Concomitant administration of certain dietary / nutritional (including grapefruit, white pepper, and strawberry fruit/Schisandra) and herbal agents is known to affect drug metabolism in humans via inhibiting CYP3A4 activity. Chemotherapy agents that are known to be metabolized by CYP3A4 include docetaxel (Taxotere), paclitaxel (Taxol), etoposide (VePesid, Etopophos, Toposar), irinotecan (Camptosar), ifosfamide (IFEX), imatinib (Glivec), vinorelbine (Navelbine), vinblastine (Velban), and vincristine (Oncovin).

    Black Cohosh: No Clinically Relevant CYP3A Interaction In Vivo
    The level of CYP3A4 inhibition is estimated at approximately 44% with black cohosh), adversely increasing the bioavailable concentration of drugs metabolized by the CYP3A4 enzyme in the blood (plasma concentrations) via the downregulation suppression of CYP3A4. However, these are strictly in vitro estimates and have been recently shown to be of no clinical significance: Bill Gurley and his coresearchers (Gurley et al. J Clin Pharmacol (2006: Assessing the Clinical Significance of Botanical Supplementation on Human Cytochrome P450 3A Activity: Comparison of a Milk Thistle and Black Cohosh Product to Rifampin and Clarithromycin) who conducted a human clinical trial assessing the effects of black cohosh (and milk thistle) supplementation on CYP3A activity, finding that black cohosh appears to have no clinically relevant effect on CYP3A activity in vivo (true also of milk thistle). This highlights the importance of in vivo confirmation of preliminary in vitro data.

    Other agents such as silymarin and ginseng, like curcumin, demonstrated no significant CYP3A4 activity. On the other hand, kava kava, like quercetin, and also grapeseed extract (GSE), proved inductive of CYP3A4.

    Citrus aurantium (Bitter orange), Panax ginseng, milk thistle (silymarin/silybin), and saw palmetto extracts taken by healthy volunteers all had no effect on the activity of CYP3A4, CYP1A2, CYP2E1, and CYP3A4 measured using model substrates (Gurley et al., Clin Pharmacol Ther (2004): In vivo assessment of botanical supplementation on human cytochrome P450 phenotypes: Citrus aurantium, Echinacea purpurea, milk thistle, and saw palmetto), but in contrast Echinacea exhibits significant effect (Gorski et al., Clin Pharmacol Ther (2004): The effect of echinacea (Echinacea purpurea root) on cytochrome P450 activity in vivo).

    Other herbal agents such as C aurantium, milk thistle, or saw palmetto extracts appear to pose a minimal risk for CYP-mediated herb-drug interactions in humans (Gurley et al., Clin Pharmacol Ther (2004): In vivo assessment of botanical supplementation on human cytochrome P450 phenotypes: Citrus aurantium, Echinacea purpurea, milk thistle, and saw palmetto); note that we have here conflicting results for saw palmetto (see Yale & Glulich, above) and it may be that different components are involved, possibly also with component-dose dependencies, much like those seen with St. John's Wort. In addition, (Gorski et al., Clin Pharmacol Ther (2004): The effect of echinacea (Echinacea purpurea root) on cytochrome P450 activity in vivo) demonstrated that interactions of Echinacea with anticancer drugs that are substrates of CYP3A4 is likely.


    v Some Common Drug-Drug Interactions v
    • Statins and Oncotherapy
      Atorvastatin (Lipitor) is another drug metabolized over the p450 cytochrome pathway and used by many breast cancer patients, and is known to be a potent CYP3A4-inhibitor, entailing significant potential for adverse interaction with other agents dependent on CYP3A4-mediated metabolism. One such, as I discussed above, is the aromatase inhibitor (AI) exemestane (Aromasin), but there are many others: restricting my attention to those with known clinically relevant interactions, these are:

      Erythromycin (antibiotic),
      Benzodiazepines (anti-anxiety agents),
      Chlorpheniramine (Chlortrimeton, an antihistamine),
      Calcium channel blockers (for cardiovascular disorders),
      Tamoxifen (tamoxifen has extremely subtle and complex pharmacokinetics and pharmacodynamics) and
      Vincristine (Oncovin], and
      Grapefruit juice, which is one of the most powerful CYP3A4-inhibitors ever discovered (with even many recorded fatal interactions).

    One workaround is to explore switching to simvastatin (Zocor) or pravastatin (Pravachol), two statins without significant p450-mediated metabolism.  Another option is rosuvastatin (Crestor), the newest and most potent of the FDA approved statins; it has been established that rosuvastatin is not extensively metabolized by  cytochrome P450 isoenzymes, and so and inhibitors of these isoenzymes do not  affect it in clinically significant ways, and although it is minimally - and clinically insignificantly - metabolized in the CYP2C9 isoenzyme pathway and to lesser extent in the CYP2C19 isoenzyme pathway,  It is not metabolized by means of cytochrome P450 (CYP) 3A4, and furthermore rosuvastatin does not have any inhibitory or inducing effects on the cytochrome P450 hepatic enzyme system (Culhane NS, Lettieri SL, Skae JR. Rosuvastatin for the treatment of hypercholesterolemia. Pharmacotherapy. 2005 Jul;25(7):990-1000). 

    It should be noted that several studies have raised some safety issues concerning statins including rosuvastatin, most notably the postmarketing analysis of Alawi Alsheikh-Ali and collegaues at Tufts (Alsheikh-Ali AA, Ambrose MS, Kuvin JT, Karas RH. The safety of rosuvastatin as used in common clinical practice: a postmarketing analysis Circulation 2005;111:3051-3057; see also Alsheikh-Ali AA, Maddukuri PV, Han H. et at. Effect of the magnitude of lipid lowering on risk of elevated liver enzymes, rhabdomyolysis, and cancer, insights from large randomized statin trials. J Am Coil Cardiol. 2007;50:409-418) which reviewed statin-associated events reported to the FDA during rosuvastatin’s first year on the market. The adverse event reports for rhabdomyolysis, proteinuria, nephropathy, or renal failure were higher for rosuvastatin than for atorvastatin (Lipitor), simvastatin (Zocor), or pravastatin (Pravachol). In answer to a petition filed with the FDA by Health Research Group of Public Citizen, the FDA acknowledged that postmarketing rosuvastatin kinetics studies found that Asian Americans experience blood levels of the drug twice as high as non-Asians, potentially predisposing to severe myopathy, and for that reason, the FDA advises that rosuvastatin be used only in low doses in Asian Americans, although Scott Grundy with the Center for Human Nutrition provides some prudent perspective on these safety issues (Grundy SM.  The Issue of Statin Safety: Where do We Stand? Circulation, June 14, 2005; 111(23): 3016 - 3019; Krumholz HM, Masoudi FA. The year in epidemiology, health services research, and outcomes research. J Am Coll Cardiol. 2006 Nov 7;48(9):1886-95. Epub 2006 Oct 17; European Perspectives: Controversies in Cardiology. Circulation. 2005;112:iv). See also the recent sobering and provactive assessment by Mark Golstein of statins and cancer risk (Goldstein MR, Mascitelli L, Pezzetta F. Do statins prevent or promote cancer? Curr Oncol. 2008 Apr;15(2):76-7), and  the sobering conclusion that "there is ample evidence that statins may promote cancer in certain segments of the population. Currently, the indications for statin therapy are based on lipoprotein levels, prevalent cardiovascular disease, other vascular risk factors, and family history. Maybe it is time for a new paradigm that also includes age extremes, prevalent cancer, a past history of cancer, and overall immunocompetence". 

    • Food-Drug Interactions
      It is now recognized that there are many potentially clinically significant food-drug interactions (Singh, B. N. &Malhotra, B. K. Effects of food on the clinical pharmacokinetics of anticancer agents: underlying mechanisms and implications for oral chemotherapy. Clin. Pharmacokinet. 43, 1127-1156 (2004), since drug-food, drug-herb or drug-drug interactions can occur when any orally administered CYP3A substrate is given concomitantly with an inhibitor or inducer of intestinal CYP activity (Scripture CD and Figg WD. Drug Interactions in Cancer Therapy. Nat Rev Cancer. 2006;6(7):546-558), and potentially adverse interactions have been raised in hundreds of studies.  To take one of dozens of examples, several studies have shown that broccoli increases CYP3A activity (Vang O, Frandsen H, Hansen KT, Sørensen JN, Sørensen H, Andersen O. Biochemical effects of dietary intakes of different broccoli samples. Differential modulation of cytochrome P-450 activities in rat liver, kidney, and colon. Metabolism. 2001 Oct;50(10):1123-9); Morel F, Langouët S, Mahéo K, Guillouzo A. The use of primary hepatocyte cultures for the evaluation of chemoprotective agents. Cell Biol Toxicol. 1997 Jul;13(4-5):323-9; Perocco P, Bronzetti G, Canistro D, et al. Glucoraphanin, the bioprecursor of the widely extolled chemopreventive agent sulforaphane found in broccoli, induces phase-I xenobiotic metabolizing enzymes and increases free radical generation in rat liver. Mutat Res. 2006 Mar 20;595(1-2):125-36; Murray M. Altered CYP expression and function in response to dietary factors: potential roles in disease pathogenesis. Curr Drug Metab. 2006 Jan;7(1):67-81), and hence can adversely interact with a broad range of CYP3A4-mediated oncotherapies, including as documented above, taxanes (docetaxel (Taxotere), paclitaxel (Taxol)), vinca alkaloids (vinorelbine (Navelbine), vinblastine (Velban), vincristine (Oncovin)), and aromatase inhibitors, all CYP3A4-mediated, as well as tamoxifen which although mainly CYP2D6-mediated, exhibits potential CYP3A-mediation in addition. So, for example, the aromatase inhibitor exemestane (Aromasin) which is extensively metabolized by CYP3A4, carries an FDA label warning that "co-medications that induce CYP3A4 may significantly decrease exposure to exemestane"; similarly for vinorelbine (Navelbine) which carries the FDA label warning that "caution should be exercised in patients concurrently taking drugs known to inhibit drug metabolism by hepatic cytochrome P450 isoenzymes in the CYP3A subfamily", with comparable warnings for docetaxel "the metabolism of docetaxel may be modified by the concomitant administration of compounds that induce, inhibit, or are metabolized by cytochrome P450 3A4", and the other hormonal and chemotherapeutic agents we identified above as CYP3A4-mediated in their metabolism; see also Buzdar AU. Pharmacology and pharmacokinetics of the newer generation aromatase inhibitors. Clin Cancer Res. 2003 Jan;9(1 Pt 2):468S-72S.

      In addition to increasing CYP3A(4) activity as documented immediately above, broccoli -  like all brassica vegetables - also increases CYP1A2 activity in humans (Lampe et al. (Carcinogenesis (2000): Brassica vegetables increase and apiaceous vegetables decrease cytochrome P450 1A2 activity in humans: changes in caffeine metabolite ratios in response to controlled vegetable diets), an adverse interaction since increased CYP1A2 function is associated with increased risk for breast cancer (Hong CC, Tang BK, Hammond GL, Tritchler D, Yaffe M, Boyd NF. Cytochrome P450 1A2 (CYP1A2) activity and risk factors for breast cancer: a cross-sectional study. Breast Cancer Res. 2004;6(4):R352-65), confirmed independently by the demonstration that CYP1A2 activity in postmenopausal women was positively associated with mammographic density (Hong CC, Tang BK, Rao V, et al. Cytochrome P450 1A2 (CYP1A2) activity, mammographic density, and oxidative stress: a cross-sectional study. Breast Cancer Res. 2004;6(4):R338-51). Thus, food components like those of brassica / cruciferous vegetables may exhibit potentially adverse activities along multiple CYP pathways: both over the p450 cytochrome hepatic enzyme system via CYP-mediated interactions with concurrent oncotherapies, as well as independently of any coadministration with oncotherapy, via adverse increase of (among others) CYP1A2 activity which is established as directly elevating breast cancer risk. In both cases the adverse impact is mediate by p450  CYP enzymes, but only the first is interactive with concurrent oncotherapy, the second mode capable of exerting adverse impact even in the absence of any active therapy.   

      This same dual mode can be seen with other agents: grapefruit juice (GFJ) exhibits strong - and strongly adverse - impact via its antioxidant furanocoumarins components bergamottin, naringin, and dihydroxybergamottin. Given this, it would be prudent to avoid all coadministration with, for example, exemestane (Aromasin), and of course with the other chemotherapies noted above as well as the vast number of other CYP3A4-mediated drugs exhibiting adverse interactive activity, as witness the well-known, extensively documented, fatality of a 29-year healthy man and allergy sufferer who consumed just two glasses of grapefruit juice while taking terfenadine (Seldane) antihistamine medication, which induced fatal cardiac arrhythmias via prolongation in the QT interval, by virtue of CYP3A4-mediated highly toxic elevated levels of terfenadine (Karch AM. The grapefruit challenge: the juice inhibits a crucial enzyme, with possibly fatal consequences. Am J Nurs. 2004 Dec;104(12):33-5). And the window of potential exposure is wide: at least 24 hours, since 24 hours after ingestion of a glass of grapefruit juice, 30% of its effect is still present and active (Schmiedlin-Ren P, Edwards DJ, Fitzsimmons ME, et al.  Mechanisms of enhanced oral availability of CYP3A4 substrates by grapefruit constituents. Decreased enterocyte CYP3A4 concentration and mechanism-based inactivation by furanocoumarins. Drug Metab Dispos. 1997 Nov;25(11):1228-33; Lundahl J, Regårdh CG, Edgar B, Johnsson G. Relationship between time of intake of grapefruit juice and its effect on pharmacokinetics and pharmacodynamics of felodipine in healthy subjects. Eur J Clin Pharmacol. 1995;49(1-2):61-7; Kane GC, Lipsky JJ. Drug-grapefruit juice interactions. Mayo Clin Proc. 2000 Sep;75(9):933-42), and  under some circumstances some small but appreciable activity may still be present at 72 hours post-ingestion.

      But in a different mode of action, grapefruit (whole fruit) consumption itself has been recently associated with elevated risk of breast cancer in a large prospective cohort study of over 50,000 postmenopausal women from five racial/ethnic groups conducted by Kristine Monroe at the USC Norris Comprehensive Cancer Center, which found that grapefruit intake was significantly associated with an increased risk of breast cancer for subjects in the highest category of intake, which was just one-quarter of one grapefruit or more per day, with the minimal consumption of one quarter of a grapefruit daily increasing the breast cancer risk by a distressing 30 percent, via clinically significant increases in plasma estrogen concentration, at alarmingly higher circulating estrogens levels (Monroe KR, Murphy SP, Kolonel LN, Pike MC. Prospective study of grapefruit intake and risk of breast cancer in postmenopausal women: the Multiethnic Cohort Study. Br J Cancer. 2007 Aug 6;97(3):440-5). And although this single study requires further confirmation in other trials to be absolutely dispositive, given broad supportive preclinical and pharmacokinetic data and compelling molecular motivation, it would be prudent for women both cancer-naive and especially those with breast cancer to exercise extreme caution in any significant consumption of dietary grapefruit.

      Given that dietary factors are estimated to account for 30% to 35% of cancer incidence, as found in the seminal studies of Sir Richard Peto, UK's leading epidemiologist and his colleague, the  late Sir Richard Doll (Doll R and Peto R. The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today. Journal of the National Cancer Institute 1981;66:1191-1308; see also Nancy Nelson. The Majority of Cancers Are Linked to the Environment. NCI Benchmarks. 2004 V 4(3). National Cancer Institute), these findings on the potentially adverse interaction of dietary factors with various oncotherapeutics, and well as the direct adverse potential of dietary components on various human cancers, independently of any active therapy or relevant interactions, are of especial weight and pertinence in avoidance of associated disease and mortality.

    • Garlic
      • Of note, garlic (and other members of the Allium genus) showed dose-dependent dual activity, elevating CYP3A4 mRNA at a lower dose of 0.1 µg/ml, whereas at higher doses garlic produced a decline, and garlic has been independently found to adversely increase the metabolic elimination of the HIV protease inhibitor, saquinavir (Invirase), a CYP3A4 substrate, in patients consuming both the anti-retroviral and garlic concurrently (Piscitelli et al, Clin Infect Dis (2002): The Effect of Garlic Supplements on the Pharmacokinetics of Saquinavir), this study being the first (but not the last) to demonstrate that garlic supplements, which are widely used, might have a detrimental effect on concomitant medications, expanding on the earlier findings of Brian Foster and colleagues at Health Canada (J Pharm Pharmaceut Sci (2001): An In Vitro Evaluation of Human Cytochrome P450 3A4 and P-glycoprotein Inhibition by Garlic) besides supplements, fresh and aged garlic exhibited similar detrimental effect.

      • Furthermore, the Foster study has further helped to clarify this issue: the study tested 6 different garlic supplements (ranging in dose from 10mg to 20mg, equivalent to 1000mg to 2000mg fresh garlic content) inhibited the cytochrome p450 CYP2C19 enzyme by 21% to 53%, and concludes that "constituents of garlic may not need to be present in high levels to elicit a pharmacological effect in order to produce a systemic or pre-systemic effect on drug disposition. The potential for the garlic products examined in this study to affect drug disposition may increase if used in combination with one or more conventional therapeutic products" and more importantly, that "that the disposition of drugs . . . could be inhibited after the co-administration with garlic or garlic products". Note that the metabolism of the widely deployed endocrine agent / aromatase inhibitor letrozole (Femara) is in part CYP2C19-mediated, and so potentially adversely affected by garlic coadministration.

      • In contrast with these in vitro findings, David Greenblatt and his colleagues at Tufts (J Nutr (2006): In Vitro Interactions of Water-Soluble Garlic Components with Human Cytochromes P450) evaluated 8 water-soluble components of aged garlic extract in order to asses potential to inhibit cytochrome-P450 (CYP) enzyme activity, for the CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, and CYP3A, observing that none of the 8 garlic components produced >50% inhibition even at high concentrations, except for S-methyl-L-cysteine and S-allyl-L-cysteine, which produced 20–40% inhibition of CYP3A compared to control. They conclude from this that drug interactions involving inhibition of CYP3A enzymes by aged garlic extract are very unlikely.

      • However, Breast Cancer Watch notes:

        (1) that although their observation there is no available clinical evidence for CYP3A inhibition in vivo by garlic or garlic components is accurate, it should be remember that there is no such in vivo data because no in vivo trial has been conducted to settle the matter one way or the other, so the absence of data for an in vivo inhibitory effect is not to be construed as the presence of positive data that shows no such effect occurs in fact.

        (2) that they consider the two exceptions (the S-methyl-L-cysteine and S-allyl-L-cysteine garlic components) of significant 20–40% inhibition of CYP3A as "modest", but a reduction this large, were it to be evidenced in vivo with oncotherapy, would be considered quite dramatic and of grave concern given the narrow therapeutic index of oncotherapeutic agents, and this suggests at least a potential for adverse interaction with such endocrine agents as anastrozole (Arimidex) whose metabolism is CYP3A-mediated, exemestane (Aromasin) which is CYP3A4-mediated, and the CYP3A4-mediated chemotherapy agents the taxanes docetaxel (Taxotere), paclitaxel (Taxol), nab-paclitaxel (Abraxane), or any of the Vinca alkaloids vinorelbine (Navelbine), vinblastine (Velban), and vincristine (Oncovin), and the platinum agent carboplatin. Without in vivo data to demonstrate no clinically significant impact of this CYP3A/3A4-inhibitory activity, the potential for adverse interaction remains (not that although on at least one of these agents, docetaxel (Taxotere) Michael Cox and coresearchers (Cox et al., Clin Cancer Res (2006): Influence of Garlic (Allium sativum) on the Pharmacokinetics of Docetaxel) found that garlic did not significantly affect the disposition of docetaxel, nonetheless as the authors admit, it cannot be excluded that Allium vegetables like garlic decreases the clearance of docetaxel in patients carrying a CYP3A5*1A allele, and hence coadministration is still problematic, as can not typically pre-identify these populations).

        (3) the Greenblatt findings, with respect to CYP2C19 appear to be in direct contradiction to the Foster findings cited above, although Breast Cancer Prevention Watch notes this may be an artifact of the overly permissive and broad definition of significant interaction in the Greenblatt study, which is > 50% inhibition. In contrast the Foster study found that the 6 garlic supplements (ranging in dose from 10mg to 20mg, equivalent to 1000mg to 2000mg fresh garlic content) inhibited the cytochrome p450 CYP2C19 enzyme by 21% to 53%, amounts they observe correctly could "elicit a pharmacological effect in order to produce a systemic or pre-systemic effect on drug disposition".

      • We see here a classical difference of disposition: for Greenblatt, potential interaction appear to have to exert very large effects (> 50%) before perceived as clinically significant, while for Foster a potential 20% or higher reduction in the activity of a drug (and possibly lower) is taken as significant in reductive capability; more in contrast. Greenblatt takes an optimistic approach to the issue of potential adverse interaction (based on in vitro findings), not observing a notable hazard unless there are explicit data that show an in vivo adverse interaction, while Foster takes a cautionary perspective until in vivo data were to show that the potentially adverse interaction in vitro is not also found in vivo, and absent such evidence, as here, views coadministration as problematic.

      • Given the narrow therapeutic index of oncotherapy agents, and their potential impact on mortality, Breast Cancer Prevention Watch would suggest erring on the side of caution: after all, for years we have known about a well-documented potentially adverse compromise of tamoxifen efficacy when coadministered with SSRI antidepressants, but many oncologists (but not David Flockhart, a principal in these findings) argued that proactive data of a clinically adverse interaction, coadministration should continue without change (while as many said "the jury is still out".

        Others, including ourselves at Breast Cancer Prevention Watch, reasoned otherwise, noting that the absence of demonstration of harm is not equivalent to the demonstration of no harm, and that given the vital operation of tamoxifen, typically administered over years, it would be imprudent to chance coadministration with an SSRI only to learn that indeed the interaction is significant, and adverse, at the clinical level, as this may entail tamoxifen failure, and even consequent patient mortality or disease recurrence due to deployment of an efficacy-compromised endocrine agent like tamoxifen.

      • On the basis therefore of the above considerations, we agree with the deductions of Sonnichsen and colleagues (Sonnichsen et al., MMW Fortschr Med (2005): Food-drug interactions: an underestimated risk) who conclude that "Certain foodstuffs or food constituents, such as, for example, grapefruit, Seville orange juice, red wine, alcoholic drinks in general, or large quantities of caffeine and garlic should be avoided during drug treatment", in keeping also with the results of Alex Sparreboom's and colleagues at the NCI in their review, finding that garlic was one of the natural agents with the "potential to significantly modulate the activity of drug-metabolizing enzymes (notably cytochrome P450 isozymes) and/or the drug transporter P-glycoprotein" and which "participate[s] in potential pharmacokinetic interactions with anticancer drugs" and also with the results of Zhou et al. (Life Sci (2004): Herbal bioactivation: The good, the bad and the ugly) who found potentially adverse interaction of the dially sulfone component of garlic as a CYP3A4 inhibitor, although an earlier study by Markowitz et al. (Clin Pharmacol Ther (2003): Effects of garlic (Allium sativum L.) supplementation on cytochrome P450 2D6 and 3A4 activity in healthy volunteers) found in contradiction that garlic extracts were unlikely to alter the disposition of coadministered medications primarily dependent on the CYP2D6 or CYP3A4 pathway of metabolism. Such not wholly convergent findings suggest the need for caution concerning coadministration until in vivo / clinical data are available to settle the issue. 

      • As can be seen from the above, although we have to date no decisive in vivo / clinical data to either definitely show harm, or the opposite, to definitively show no harm, there remains the potential for adverse interaction between Allium vegetables and certain oncotherapies. One can balance this against the very real potential for other beneficial activities of garlic and Allium components on health, and on cancer, but we don't know how the balance of benefit / harm will swing, hence our own cautionary stance.

    • Brassica / Cruciferous Vegetables - The Safety of Sulforaphane
      One final issue on components of brassica vegetables concerns the component sulforaphane: as Zhou et al. (Mol Pharmacol (2006): The dietary isothiocyanate, sulforaphane is an antagonist of the human steroid and xenobiotic nuclear receptor (SXR) [pdf]) observe, this biologically active phytochemical found abundantly in broccoli, can significantly down-regulate cytochrome P450 3A4 (CYP3A4) expression in human primary hepatocytes, and although this mechanism serves as part of the foundation for its anticancer and chemopreventive activity, there may be some potential for adverse interaction with CYP3A4-mediated agents such as exemestane (Aromasin), and we await clinical studies to determine whether such interaction exerts clinically significant impoact on concurrent administration (see also Maheo et al., Cancer Res (1997: Inhibition of cytochromes P-450 and induction of glutathione S-transferases by sulforaphane in primary human and rat hepatocytes, who first reported the CYP3A4 enzyme operation in sulforaphane).

      And the review of Paolini & Nestle (Mutat Res (2003): Pitfalls of enzyme-based molecular anticancer dietary manipulations: food for thought) found that "cruciferous isothiocyanates such as sulforaphane, most often considered as beneficial phase-II detoxifying system inducers, turn out to be genotoxics or strong promoters of urinary bladder and liver carcinogenesis as well as inducing cell cycle arrest and apoptosis".
    • Sulforaphane is an isothiocyanate (isothiocyanates being the family of compounds found in large amounts in cruciferous vegetables in the form of the thioglucoside precursors (glucosinolates)) that has been isolated from SAGA broccoli as the major phase II enzyme inducer present in organic solvent extracts of this vegetable. The (chemo)protective effect of sulforaphane, an isothiocyanate - - which is liberated from glucoraphanin (GRP), its glucosinolate precursor, by myrosinase hydrolysis, is believed to involve the induction of Phase-II metabolizing enzymes which are active in the detoxification of many carcinogens and ROS (reactive oxygen species), and by this protecting cells against DNA damage and subsequent malignant transformation. However, as discovered by Paolini et al (Carcinogeneis (2004): Induction of cytochrome P450, generation of oxidative stress and in vitro cell-transforming and DNA-damaging activities by glucoraphanin, the bioprecursor of the chemopreventive agent sulforaphane found in broccoli) that:

      (1) in some cases these enzymes also bioactivate several hazardous chemicals, and
      (2) that despite sulforaphane's projected benefits, overlooked is its unknown effects on the Phase-I enzyme systems involved in the bioactivation of a variety of carcinogens, where not only has sulforaphane been shown to inhibit the CYP2E1 cytochrome P-450 enzyme involved in the activation of a variety of carcinogen, but also to down-regulate CYP3A4 expression (as shown by the separate Zhou and Maheo studies, cited above), and this raises issues of potential significant and possibly adverse interaction with CYP3A4-mediated oncotherapy agents such as endocrine agent exemestane (Aromasin), taxanes (docetaxel (Taxotere), paclitaxel (Taxol)), and nab-paclitaxel (Abraxane) or any of the Vinca alkaloids (vinorelbine (Navelbine), vinblastine (Velban), vincristine (Oncovin)), and the platinum agent carboplatin (Paraplatin), suggesting caution of coadministration of high-sulforaphane-content dietary or supplemental sources with any of the CYP3A4-dependent classes of oncotherapy just notes, until further in vivo or ideally human clinically studies can demonstrate compellingly the safety ands non-problematic nature of such coadministration.
    • Independent of this, there is another disturbing aspect of sulforaphanes induction of Phase-I CYP bioactivating enzymes: sulforaphane is as we noted above liberated from its glucosinolate precursor glucoraphanin (GRP), and there is some evidence that GRP may possess co-carcinogenic properties. Indeed, by inducing Phase-I CYP bioactivating enzymes, GRP may trigger the conversion of benzo[a]pyrene to carcinogenic reactive intermediates like diol-epoxides, and recent studies have shown that a cruciferae-based diet containing a selection of brassicaceous vegetable that includes broccoli, Brussel sprouts or cauliflower, leads to a significant increase in Phase-I enzymes such as CYP1A1/2, which can bioactivate PAHs, dioxins, aromatic amines and nitrosamines (as reported by Paolini et al (Carcinogeneis (2004): Induction of cytochrome P450, generation of oxidative stress and in vitro cell-transforming and DNA-damaging activities by glucoraphanin, the bioprecursor of the chemopreventive agent sulforaphane found in broccoli), and priorly confirmed as well in the study by Vistisen et al. (Carcinogenesis (1992): Foreign compound metabolism capacity in man measured from metabolites of dietary caffeine) who found that in nine healthy volunteers daily ingestion of 500 g of broccoli for 10 days increased the CYP1A2 ratio adversely by an average of 12% compared to a comparable diet of non-cruciferous green vegetable, see also Lampe et al. (Carcinogenesis (2000): Brassica vegetables increase and apiaceous vegetables decrease cytochrome P450 1A2 activity in humans: changes in caffeine metabolite ratios in response to controlled vegetable diets).
    • The adverse impact of the brassica diet not only hinges on adverse interactions across CYP3A4 as documented extensively in this review, but also on CYP1A2 activity and is increased by cigarette smoke, well-cooked meat, and unfortunately by cruciferous vegetables and this is adverse, since CYP1A2 metabolizes various environmental procarcinogens, such as heterocyclic amines (HCAs), nitrosamines and aflatoxin B1, in keeping with the research of Lampe et al. (Carcinogenesis (2000): Brassica vegetables increase and apiaceous vegetables decrease cytochrome P450 1A2 activity in humans: changes in caffeine metabolite ratios in response to controlled vegetable diets)), where it was found that that under controlled dietary conditions, at moderate levels of intake (428 g), brassica vegetables increased (while apiaceous vegetables decreased, and allium vegetables did not change) CYP1A2 activity by 18 - 37%, when compared with a basal, vegetable-free diet.

    • Brassica / Cruciferous Vegetables - I3C, DIM
      Epidemiological studies provide evidence that the consumption of cruciferous vegetables protects against cancer more effectively than the total intake of fruits and vegetables. The indole-3-carbinol (I3C) component in brassica and cruciferous vegetables may may also be protective in cervical and possibly prostate cancers, probably by enhancing 2-hydroxyestrone (an estrogen receptor antagonist - non-stimulative of breast tumors - produced in estrogen breakdown) at the expense of 16-hydroxylation (an estrogen receptor agonist - promoting breast tumors - also produced in estrogen breakdown), thus shifting the ratio to the favorable estrogen breakdown product (see Keck and Fenley, Integr Cancer Ther: Cruciferous vegetables: cancer protective mechanisms of glucosinolate hydrolysis products and selenium). Epidemiological, laboratory, animal and translational studies increasingly indicate that dietary indole-3-carbinol (I3C) prevents the development of estrogen-enhanced cancers including breast, endometrial and cervical cancers (Auborn et al., J Nutr: Indole-3-carbinol is a negative regulator of estrogen) (see also von Poppel, Exp. Med. Biol: Brassica vegetables and cancer prevention. Epidemiology and mechanisms; Terry et al., JAMA: Brassica vegetables and breast cancer risk, where it was found that consumption of brassica vegetables was inversely associated with breast cancer risk, especially 1 to 2 servings per day, lowers the risk of breast cancer by as much as 20% to 40%, possibly by shifting the pathway of estrogen metabolism) (Ambrosone et al., J Nutr: Breast Cancer Risk in Premenopausal Women Is Inversely Associated with Consumption of Broccoli, a Source of Isothiocyanates, but Is Not Modified by GST Genotype, which found that vegetables may play an important role in decreasing the risk of premenopausal, but not postmenopausal, breast cancer) (Fowke et al., Cancer Res: Urinary isothiocyanate levels, brassica, and human breast cancer, which found that "greater Brassica vegetable consumption, as measured by the urinary ITC biomarker, was associated with significantly reduced breast cancer risk among Chinese women"; also Fowke et al., Cancer Epidemiol. Biomarkers Prev: Urinary Isothiocyanate Excretion, Brassica Consumption, and Gene Polymorphisms among Women Living in Shanghai, China) (Bell et al, Gynecol. Oncol: Placebo-controlled trial of indole-3-carbinol in the treatment of CIN) (Shukla et al., Teratog Carcinog Mutagen: Antigenotoxic potential of certain dietary constituents).

      One specific dietary regimen that has been reported to be effective is a high fiber diet including the consumption of 50 g of cabbage or 100 g of broccoli twice weekly; see Lord et al., Altern Med Rev:       Estrogen metabolism and the diet-cancer connection: rationale for assessing the ratio of urinary hydroxylated estrogen metabolites [pdf]) (Brignall, Altern Med Rev: Prevention and treatment of cancer with indole-3-carbinol [pdf]) (Kelloff et al., J Nutr: Progress in cancer chemoprevention: development of diet-derived chemopreventive agents, where it is suggested that the anti-breast cancer activity of I3C may be exerted through modulation of cytochrome P450-dependent estradiol metabolism, by enhancing 2-hydroxyestrone (estrogen receptor antagonist) at the expense of 16-hydroxylation (estrogen receptor agonist. And Reed et al. (Cancer Epidemiol Biomarkers Prev (2005): A Phase I Study of Indole-3-Carbinol in Women: Tolerability and Effects) have recently determined with respect to I3C supplementation that no more than 400 mg I3C daily would elicit maximal protective effect.

      However, there are significant concern surrounding the issue of potential adverse interactions through the P450 cytochrome family of enzymes, especially on the hepatic microsomal metabolism of tamoxifen (TAM): so Daniel Parkin and Danuta Malejka-Giganti at the University of Minnesota (Parkin et al., Cancer Detect Prev (2004): Differences in the hepatic P450-dependent metabolism of estrogen and tamoxifen in response to treatment of rats with 3,3'-diindolylmethane and its parent compound indole-3-carbinol) in another rat study found that although metabolism of TAM was unaffected by DIM, formation of N-desmethyl-TAM was increased 3-fold by I3C, and since N-desmethyl-TAM is transformed to a genotoxic metabolite, this appears to suggest that dietary exposure to I3C may enhance hepatic carcinogenicity of TAM in the rat.

      However, here again, conflicting results exists: so Dustin Leibelt and colleagues at Oregon State University (Leibelt et al., Toxicol Sci (2003): Evaluation of Chronic Dietary Exposure to Indole-3-Carbinol and Absorption-Enhanced 3,3'-Diindolylmethane in Sprague-Dawley Rats) failed to detect any direct toxicity by long-term exposure to I3C and DIM, even at doses up to approximately 5–7 times the daily dose recommended by commercial suppliers of I3C supplements, and at exposure 10 times higher than the current human dose for DIM, and the researchers concluded that data from their present study confirms results from short-term studies indicating that both I3C and DIM are relatively nontoxic compounds, and furthermore confirm earlier long-term feeding studies in other models, including the rainbow trout and the same strain of rat used in the present study, that I3C is not a complete carcinogen, a finding also confirmed by Gary Stoner and co-researchers (Stoner et al., Carcinogenesis (2002): Development of a multi-organ rat model for evaluating chemopreventive agents: efficacy of indole-3-carbinol) who nonetheless warn that I3C may not an appropriate chemoprotective agent for human use in that it appears to both inhibit (breast, colon) and promote (liver) carcinogenesis. And the Leibelt study warns of two distinct concerns: (1) that the prolonged use of I3C for cancer chemoprevention exhibits a potential for promotion of liver neoplasms, although they prudently admit that the long-term post-initiation effects of I3C in hepatocarcinogenesis are not consistent across species (trout, rats, black mice), leaving open what the real risk is, if any, in the human context; and (2) the induction of CYP enzymes by I3C, especially those of the 1A subfamily, could be a cause for concern, as these play a role in activation of polycyclic aromatic hydrocarbons (PAH) and aromatic amines with known toxicities, a concern that appears not to be shared with DIM. The reason for this may be that in the acidic conditions of the stomach after oral exposure, I3C becomes a complex mixture more than 20 different I3C-derived compounds, including DIM, all having various pharmacological/toxicological effects, while DIM is relatively more stable in acid and does not robustly undergo further condensation reactions, suggesting that the more stable DIM component may be the safer compound to deploy in the human context.

      However, I3C yielded dose-dependent increases in the hepatic P450 level according to the research of Malejka-Giganti and coresearchers at the University of Minnesota (Malejka-Giganti et al., Cancer Epidemiol Biomarkers Prev (2003): Effects of treatment of rats with indole-3-carbinol or 3,3'-diindolylmethane on the hepatic P450-dependent metabolism of estrogen and tamoxifen) who in their animal study of female Sprague-Dawley rats tested 5, 25 and 250 mg/kg body weight of I3C and DIM at 8.4 and 42 mg/kg body weight, finding that oral intake of I3C or DIM at lower dose levels did not alter CYP-mediated metabolism of tamoxifen, and hence, would not alter its therapeutic efficacy. Since for a human female weighing 140 lbs, equivalent to about 64 kilograms (kg), the CYP-mediated TAM metabolism altering dose (250/mg/kg) would map to 16,000 mg, which is easily 40 times greater than the recommended I3C dosing of 400mg/daily, and from these findings it would appear that doses up to 1600mg/daily would be without adverse interactions on tamoxifen metabolism and efficacy, assuming the same 140 lbs female, and that 400mg/daily IC3 ingestion is at a level to assure no oncotherapy interference with tamoxifen -  but given conflicting findings in the  evidence base, this can be no means be considered dispositive.

      Thus, we note the conclusions of a recent comprehensive review by EG Rogan with the Eppley Institute for Research in Cancer and Allied Diseases at the University of Nebraska Medical Center (EG Rogan, In Vivo (2006): The natural chemopreventive compound indole-3-carbinol: state of the science) who notes that "although I3C has been shown to protect against tumor induction by some carcinogens, it has also been observed to promote tumor development in animal models" and that in humans, concerns have been raised that I3C might increase the formation of estrogen metabolites that induce or promote cancer". In this connection, the in vivo component of I3C, 3,3'-diindolylmethane (DIM) is unlike, its precursor, I3C itself, not highly enzyme-inducing, where it appears from the evidence base that it is the unwanted enzyme induction by I3C that accounts for any perceived adverse tumor promotion activity by I3C, and lacking these unwanted enzyme-inducing effects, DIM, which appears to share the positive efficacy of I3C in breast and cervical carcinomas, would be suggested as the safer compound in human use (and in keeping with the conclusion of Leibelt, cited above, that "Long-term exposure to DIM produced no observable toxicity, and comparison to I3C indicates that DIM is a markedly less efficacious inducer of CYP in the rat at doses relevant to human supplementation").

      Further Evidence of P450 CYP-mediated Harm of Brassica / Cruciferous Components
      Against this, animal studies have strongly suggested promotion of endometrial adenocarcinoma by I3C which appears to be correlated with the induction of CYP1A and CYP1B enzymes and sequential formation of toxic estradiol catechol metabolites, suggesting AhR-mediated pathways may be critical (Yoshida M, Katashima S, Ando J, et a. Dietary indole-3-carbinol promotes endometrial adenocarcinoma development in rats initiated with N-ethyl-N'-nitro-N-nitrosoguanidine, with induction of cytochrome P450s in the liver and consequent modulation of estrogen metabolism. Carcinogenesis. 2004 Nov;25(11):2257-64), and with respect to DIM, in vitro studies have shown it to exhibit estrogenic activity in certain cancer cells, via ligand-independent activation of ER (Riby JE, Chang GH, Firestone GL, Bjeldanes LF, et al. Ligand-independent activation of estrogen receptor function by 3, 3'-diindolylmethane in human breast cancer cells. Biochem Pharmacol. 2000 Jul 15;60(2):167-77; Leong H, Riby JE, Firestone GL, Bjeldanes LF. Potent ligand-independent estrogen receptor activation by 3,3'-diindolylmethane is mediated by cross talk between the protein kinase A and mitogen-activated protein kinase signaling pathways. Mol Endocrinol. 2004 Feb;18(2):291-302; Tilton SC, Hendricks JD, Orner GA, Pereira CB, Bailey GS, Williams DE. Gene expression analysis during tumor enhancement by the dietary phytochemical, 3,3'-diindolylmethane, in rainbow trout. Carcinogenesis. 2007 Jul;28(7):1589-98). 

      In addition, it now appears (Paolini M, Perocco P, Canistro D, et al. Induction of cytochrome P450, generation of oxidative stress and in vitro cell-transforming and DNA-damaging activities by glucoraphanin, the bioprecursor of the chemopreventive agent sulforaphane found in broccoli. Carcinogenesis. 2004 Jan;25(1):61-7) that regular administration of the glucosinolate precursor glucoraphanin (GRP) by myrosinase hydrolysis actually increases rather than decreases cancer risk, especially for individuals exposed to mutagens and carcinogens in the environment (e.g., tobacco smoke, and other certain industrial exposures), via phase-II metabolizing enzymes which, although generally have been taken as beneficial, can bioactivate several hazardous chemicals. And we are nonetheless left with unknown effects of brassica / cruciferous even on phase-I enzyme systems involved in the bioactivation of a variety of carcinogens, which induce phase-I carcinogen-activating enzymes including activators of carcinogenic PAHs (polycyclic aromatic hydrocarbons), and concurrently with this phase-I induction GRP over-generates reactive oxygen species (ROS) while also facilitating the metabolic activation of the PAH benzo[a]pyrene to reactive carcinogenic forms, along with observed DNA-damaging genotoxicity. And these adverse effects were seen at dietary-realistic levels, as Moreno Paolini at the University of Bologna and coresearchers (see previous) have demonstrated: despite glucosinolate content in brassica / cruciferous vegetables varying with species, cultivation, and the parts of the plant used, the mean content was 100 mmol/100 g fresh weight (a typical portion of vegetables), corresponding to 26 mg GRP (55% of the total), which was sufficient to induce a powerful and highly significant increase (from 4.4 to 13-fold) of several phase-I carcinogen-metabolizing enzymes following a single or repeated treatments of GRP, with a significant increase in CYP1A1/2 enzymes which activate polychlorinated biphenyls, aromatic amines and PAHs, CYP3A1/2 enzymes activating nitropyrenes, aflatoxins and PAHs, CYP2B1/2 enzymes activating olefins and halogenated hydrocarbons) and CYP2C11 enzymes activating nitrosamines, aflatoxins and ochratoxins, all of which led the researchers to conclude that "The observed CYP induction following GRP administration suggests that GRP may possess co-carcinogenic properties" (see also Lampe JW, King IB, Li S, et al. Brassica vegetables increase and apiaceous vegetables decrease cytochrome P450 1A2 activity in humans: changes in caffeine metabolite ratios in response to controlled vegetable diets. Carcinogenesis. 2000 Jun;21(6):1157-62). This brassica / cruciferous components like GRP may instead of behaving chemopreventively, in fact exert adverse toxicological effects via the induction of carcinogen-bioactivating enzymes, and via generating oxidative stress and genotoxic DNA damage, of especial concern for individuals exposed to mutagens and carcinogens known to be metabolized by phase-I bioactivating enzymes, include of course cancer patients who have have impaired DNA repair mechanisms (also in agreement with Paolini & Nestle (Mutat Res (2003): Pitfalls of enzyme-based molecular anticancer dietary manipulations: food for thought).

      Another potential for harm comes from a wholly different mechanism -       activation of estrogenicity: researcher Jacques Riby and colleagues at the Division of Nutritional Sciences and Toxicology of University of California, Berkeley found that DIM (3,3′-Diindolylmethane) - a major in vivo product of acid-catalyzed oligomerization of I3C (indole-3-carbinol) present in brassica vegetables like broccoli and others in the  genus - is a promoter-specific activator of estrogen receptor (ER) function in the absence of (17β-)estradiol, inducing proliferation of these cells in the absence of steroid, suggesting promoter-specific, ligand-independent activation of ER signaling by DIM, functioning as therefore a selective activator of ER function (Riby JE, Chang GH, Firestone GL. Ligand-independent activation of estrogen receptor function by 3, 3'-diindolylmethane in human breast cancer cells. Bjeldanes LF. Biochem Pharmacol. 2000 Jul 15;60(2):167-77). 

    • Breast Cancer Watch Warning: The Insufficiency of Myrosinase Inactivation of Dietary Brassica / Cruciferous Components
      It is often cited in defense of the safety of brassica / cruciferous consumption concurrently with various oncotherapies whose metabolism is CYP-mediated across the same p450 CYP enzymes that are influenced by brassica / cruciferous vegetables, that cooking can inactivate myrosinase, the enzyme which hydrolyzes glucosinolates in cruciferous and brassica vegetables into biologically active isothiocyanates (ITC). However, the fallacy here is the failure to realize, well-documented, that even if myrosinase has been inactivated, intestinal microbial metabolism of glucosinolates also contributes to ITC exposure (Rungapamestry V, Duncan AJ, Fuller Z, Ratcliffe B. Effect of cooking brassica vegetables on the subsequent hydrolysis and metabolic fate of glucosinolates. Proc Nutr Soc. 2007 Feb;66(1):69-81), as colon microflora appear to be able to catalyze glucosinolate hydrolysis when vegetables are cooked, so that isothiocyanates still arise despite cooking, and although this is apparently at a lower level (10% to 20%), there is absolutely no reassuring data to show that such activation by bacterial myrosinase isn't sufficient to support adverse interaction with active oncotherapy. It isn't just the range of methods used to prepare these foods and the associated degree of myrosinase inactivation that determines potential adverse interaction, but also the activity level of the consumers’ dentition / chewing, as well as the consumer's colonic microbes, that all contribute to an individual's risk exposure, and indeed this is also dependent on genetic polymorphisms in biotransformation enzymes that metabolize ITC, and possibly as well receptors and transcription factors that interact with these compounds, all factors independent of cooking inactivation and contributing wide individual variation which may sustain adverse risk at clinically significant levels in any one individual (on bacterial glucosinolate metabolism occurring in the digestive tract and the  modulate of the process of glucosinolate metabolism in relation to the composition and activity of the colon microflora, see Krul C, Humblot C, Philippe C, et al. Metabolism of sinigrin (2-propenyl glucosinolate) by the human colonic microflora in a dynamic in vitro large-intestinal model. Carcinogenesis. 2002 Jun;23(6):1009-16). And direct evidence of colonic hydrolysis of glucosinolates in human subjects themselves has been provided in a study by Serkadis Getahun and Fung-Lung Chung with the American Health Foundation which documented a linear increase in the formation of isothiocyanates for 2 hours after incubating with bowel microflora cooked watercress containing glucosinolates but no plant myrosinase (Getahun SM, Chung FL. Conversion of glucosinolates to isothiocyanates in humans after ingestion of cooked watercress. Cancer Epidemiol Biomarkers Prev. 1999 May;8(5):447-51).

      And as Lilli Link at Columbia and John Potter at the Fred Hutchinson Cancer Research Center have noted, the average excretion of isothiocyanates in the 24-hour urine collection was still a non-trivial 20.6 µmol even in human subjects who ate broccoli steamed for 15 minutes, confirmed also in the earlier research of Clifford Conaway's team at the American Health Foundation (Conaway CC, Getahun SM, Liebes LL, et al. Disposition of glucosinolates and sulforaphane in humans after ingestion of steamed and fresh broccoli. Nutr Cancer 2000;38:168–78; Link LB, Potter JD. Raw versus cooked vegetables and cancer risk. Cancer Epidemiol Biomarkers Prev. 2004 Sep;13(9):1422-35), and this independent of possibly further enhancement of level under variable circumstances of the additional affecting factors such as gut microflora, pH and the presence of various cofactors. Furthermore, glucosinolate hydrolysis in the gut can produce a range of breakdown products in addition to the isothiocyanates, and the yields of such different groups of metabolites, including isothiocyanates, nitriles and epithioalkane nitriles, and the factors that may affect these yields after glucosinolate ingestion, are not well understood, but the delayed release of isothiocyanates in significant quantities after cooking - which supposedly should have inactivated such production - has been decisively demonstrated recently by Gabrielle Rouzaud's team at Aberdeen (Rouzaud G, Young SA, Duncan AJ. Hydrolysis of glucosinolates to isothiocyanates after ingestion of raw or microwaved cabbage by human volunteers. Cancer Epidemiol Biomarkers Prev. 2004 Jan;13(1):125-31), via the action of the colon microflora when dietary glucosinolates reached the colon, and such colonic hydrolysis - as opposed to and in addition to myrosinase-mediated hydrolysis - of glucosinolates may yield other active products such as nitriles in addition to isothiocyanates. Finally, it has been shown by Fekadu Kassie's team in Vienna collaborating with the UK Institute of Food Research that juices of Brussels sprouts, white and green cabbage, cauliflower, kohlrabi, broccoli, turnip, and black radish all induce pro-mutagenic genotoxic activity (Kassie,F., Parzefall,W., Musk,S., et al. Genotoxic effects of crude juices from Brassica vegetables and juices and extracts from phytopharmaceutical preparations and spices of cruciferous plants origin in bacterial and mammalian cells. Chem Biol Interact. 1996 Sep 27;102(1):1-16).

      Another fallacy should also be noted here: not all brassica / cruciferous vegetables are created equal: although heating to 70 °C and above decreased the formation of both sulforaphane and sulforaphane nitrile products in broccoli florets, this was not true of broccoli sprouts, whose sulforaphane content was unaffected by such heating (Matusheski NV, Juvik JA, Jeffery EH. Heating decreases epithiospecifier protein activity and increases sulforaphane formation in broccoli. Phytochemistry. 2004 May;65(9):1273-81), and compared to boiling, cooking by steaming, microwaving and stir-fry did not produce significant loss of glucosinolates the content of the 7 major glucosinolates in broccoli, Brussels sprouts, cauliflower and green cabbage (Song L, Thornalley PJ. Links Effect of storage, processing and cooking on glucosinolate content of Brassica vegetables. Food Chem Toxicol. 2007 Feb;45(2):216-24; Galgano F, Favati F, Caruso M, Pietrafesa A, Natella S. The influence of processing and preservation on the retention of health-promoting compounds in broccoli. J Food Sci. 2007 Mar;72(2):S130-5; Rungapamestry, V, Duncan, AJ, Fuller, Z & Ratcliffe, B. Changes in Glucosinolate Concentrations, Myrosinase Activity, and Production of Metabolites of Glucosinolates in Cabbage (Brassica oleracea Var. capitata) Cooked for Different Durations. Agric. Food Chem., 54 (20), 7628 -7634, 2006).   

      The prudent and cautionary advice of Gary Stoner at Ohio State University is therefore worth remembering: "With the exception of the studies cited in this report (6,22,23), no other attempts have been made to weigh chemoprotective benefits against promotional risk for I-3-C. In spite of the hope that I-3-C might be a non-genotoxic alternative for tamoxifen or synergin for adjuvant therapy, the risk of promoting colon and liver cancer, especially if I-3-C is used as a `health food' by the presumably disease-free general public is unwise and potentially dangerous" (Stoner et al., Carcinogenesis (2002): Development of a multi-organ rat model for evaluating chemopreventive agents: efficacy of indole-3-carbinol).  Similarly, Roderick Dashwood at the University of Hawaii who notes that some studies "provide clear evidence for promotion or enhancement of carcinogenesis, depending upon the initiator, exposure protocol and species. In the absence of detailed information on the inhibitory and in particular, promotional mechanisms, it would seem advisable to proceed with caution before including I3C in extensive human clinical trials" (Dashwood RH. Indole-3-carbinol: anticarcinogen or tumor promoter in brassica vegetables? Chem Biol Interact. 1998 Mar 12;110(1-2):1-5).

  • Summary of Adverse Food-Oncotherapy Interactions, Known To Date
     The major food items with some evidence of potentially adverse interaction during concomitant oncotherapy across the cytochrome p450 hepatic enzyme system are:
    • brassica / cruciferous vegetables
      [arugula, bok choi, broccoli, brussel sprouts, cabbage, cauliflower, collards, daikon, horseradish, kale, kohlrabi, mizuna, mustard greens, napa (or Chinese) cabbage, radish, rutabaga, tatsoi, turnips, wasabi, and watercress]
      • Note: garlic powder remains unproblematic if and only if used not at food-item-levels but at light seasoning-levels (no more than a sprinkling or "small pinch")
    • the juice and fruit of grapefruit and seville oranges;
    • the juices of wild grape, pomegranate, and black raspberry (and probably others not yet tested);
    • extracts and teas of licorice, goldenseal and chamomile;
    • evening primrose oil (EPO) and borage oil;
    • the spices sage, thyme, and cloves
      (which like garlic powder, remain unproblematic if and only if used at light seasoning-levels)

    with these findings subject to change and refinement under additional data.

    • Apiaceous Vegetables
      Against this adverse impact of brassica vegetables, Breast Cancer Prevention Watch finds intriguing the fact that apiaceous vegetables (carrots, parsnips, celery, dill and parsley) decreased mean CYP1A2 activity by ~13–25%, which suggest to us - but note without any clinical data to support the hypothesis - that the differential CYP1A2 response to the brassica and apiaceous vegetable diets may be leveraged to in largely past cancel out or nullify the adverse CYP1A2 impact of the brassica components by co-consumption with apiaceous vegetables.

    • Lapatinib Dosing and Meal-based High-Fat Consumption
      Given all the negative press on the potential adverse interactions CYP3A4-metabolized drugs and CYP3A4 inhibitors or inducers, we have recently encountered a new twist on the theme, the suggestion that such interaction could be leveraged positively, even to economic advantage. So Allison Grandley reports on this writing for the Annie Appleseed Project (Grandley A. Enhancing Drug Action w/Food & Grapefruit Juice. Annie Apple Seed Project. Available at: http://annieappleseedproject.stores.yahoo.net/endracwgrju.html. Accessed April 10, 2008), a non-profit medical news reporting service which, it should be remembered, also brought us an extensive piece by an environmental chemist Ralph Reed on bras and breast cancer that argues seriously - against current evidence and consensus - for the unorthodox view popularized in Sydney Ross Singer and Soma Grismaijer's book Dressed to Kill that wearing bras is associated with a staggering 125-fold elevated risk of breast cancer (Ree R. Bras and Breast Cancer. Annie Apple Seed Project. Available at: http://annieappleseedproject.stores.yahoo.net/brasbreascan.html. Accessed April 10, 2008). Writing about the research findings of University of Chicago oncologists Mark Ratain and Ezra Cohen, Grandley (Ratain MJ, Cohen EE. The value meal: how to save $1,700 per month or more on lapatinib. J Clin Oncol. 2007 Aug 10;25(23):3397-8) - among numerous others in both the popular and medical press - quotes Dr. Ratain: "Simply by changing the timing — taking this medication with a meal instead of on an empty stomach — we could potentially use 40% or even less of the drug," Dr. Ratain said in a news release. "Since lapatinib costs about $2900 a month, this could save each patient $1740 or more a month". Colleague and co-author Dr. Cohen continues with faint caution, suggesting that "Dozens, if not hundreds, of drugs should be studied in this way, the authors suggest. "If we understood the relationship between, say, grapefruit juice and common drugs, such as the statins, which are taken daily by millions of people to prevent heart disease, we could save a fortune in drug costs". 

      We would strongly advise against any such suggestion, and in fact - apparently unknown to the Annie Apple Seed Project writer Allison Grandley - the authors of the study, Marc Retain and Ezra Cohen of the University of Chicago, do NOT in fact themselves advise taking lapatinib at reduced dose with a meal, despite their soaring rhetoric to the media; they state clearly in their article that they "do not recommend off-label administration of lapatinib outside of a clinical trial", and to do otherwise would of course have grave medico-legal implications for the authors, as despite the appearance to the contrary there is not one iota of clinical data to suggest the safety and efficacy of any mode of administration of lapatinib other than the sanctioned fasting mode, nor for the safety and efficacy of lapatinib at any dose reduction from the sanctioned schedule, whether with or without food. Meal-based dose reduction may potentially compromise the treatment benefit of an effective therapy for advanced or metastatic breast cancer: fasting conditions are, by definition, reproducible, whereas taking a meal (along with a long-term drug administration by oral route) is not replicable and an obvious source of heterogeneity in terms of inter-patient and/or intra-patient pharmacokinetic variability. The risk of taking lapatinib with food (no matter if standardized or not) is to generate grossly unpredictable plasma concentrations and to consequently worsen efficacy and/or adverse effects. The pharmacokinetic data on lapatinib clearly indicate that decreasing the dose and using the contents of a meal to adjust bioavailability in order to achieve therapeutic plasma concentrations is not only unreliable but potentially highly dangerous. Dietary manipulations with inconsistent effect on drug exposure are to be avoided in clinical use, as the clinical benefit of such maneuvers unknown and potentially of significant harm to patients via compromising a drug's efficacy or toxicity.

      Furthermore, it should be noted that the Dartmouth study by Nandi Reddy (Reddy N, Cohen R, Whitehead B, et al: A phase I, open-label, three period, randomized crossover study to evaluate the effect of food on the pharmacokinetics of lapatinib in cancer patients. Clin Pharmacol Ther 81:S16-S17, 2007) that Marc Retain and Ezra Cohen of the University of Chicago cite as support is a phase I open label pharmacokinetic study that suggests that full dose, not reduced dose, lapatinib exposure is significantly increased when taken with a high-fat meal as compared with a fasted state; the authors of this article did not study the exposure from a lower dose of lapatinib (250 or 500 mg) taken with a meal compared to the 1,250-mg dose taken 1 hour before or after meals, and so such exposure is unknown, and hence this study is wholly insufficient to found any conclusion about reduced-dose lapatinib, such a conclusion requiring further clinical studies including a relative bioavailability study evaluating lower lapatinib dose taken with a meal versus a 1,250-mg dose taken without a meal. Overlooked by Retain and Cohen are both inter- and intra-patient variability in bioavailability, along with dietary effects on concomitant medications, and differing patterns of oral intake and food constituents. Individual food intake varies from time to time, and the meal's composition (caloric intake and fat, protein, and carbohydrate content) can have erratic and unpredictable effects on gastric emptying and intestinal motility in any given individual, resulting in no reliably assured drug level. Indeed, FDA submitted preapproval clinical studies examined the average increase in lapatinib's bioavailability with a low-fat and a high-fat meal, and found that individual patients taking the recommended dose with food will have highly variable (52% coefficient of variability) and unpredictable changes in absorption (Rahman A, Pazdur R, Wang Y, Huang SM, Lesko L. The value meal: effect of food on lapatinib bioavailability. J Clin Oncol. 2007 Nov 20;25(33):5333-4). Data presented by Nandi Reddy of Dartmouth Hitchcock Medical Center during the ASCPT meeting (see above) showed that this food effect showed broad variablity between individual patients, with 48% inter-patient variability in apparent oral clearance, yielding 68% variability in AUC systemic exposure (area under the curve). However, this still underrepresents the magnitude of variability experienced across individual study, sometimes dramatic in range, from a slight decrease to as high as a 24-fold increase, and as Kevin Koch and GlaxoSmithKline (GSK) coresearchers have observed, participants in the controlled studies ate precisely identical meals at the same time and consistently each day as required by the protocol, an artificial scenario rarely if ever seen in the real world (Koch KM, Beelen AP, Ho PT, Roychowdhury DF. The value of label recommendations: how to dose lapatinib. J Clin Oncol. 2007 Nov 20;25(33):5331-2). Unfolding in such eating pattern variations may countervail proposed cost savings by increased toxicity or unfortunate disease progression if appetite were sufficiently depressed or inter-patient variability dealt some unlucky patient a suboptimal plasma level of the agent.

      Furthermore, as noted by Atiqur Rahman with CDER at the FDA (see Rahman et al., above), The AUC ratios (fed/fasted ratio) could range from less than one for some individuals to as high as 24-fold increased exposure if accompanying a high-fat meal, translating to the scenarios of some patients being under-dosed while others being massively and dangerously overdosed from the mean-adjusted dose of lapatinib. This is especially serious given the QT prolongation potential of lapatinib, as found in a dose escalation study in patients with advanced cancer which observed a relationship between lapatinib concentration and the QT interval, so that high concentration induced artificially by food consumption and food content manipulation could led to highly adverse cardiac events such as cardiac rhythm disturbances including fatal cardiac dysrhythmias like torsade de pointes (FDA Warning Letter. Re: NDA # 22-059 GlaxoSmithKline TYKERB (lapatinib) Tablets MACA41S #15851. Released by FDA: 11/21/07). The US FDA Clinical Pharmacology and Biopharmaceutics Review (Clinical Pharmacology and Biopharmaceutics Review. Center for Drug Evaluation and Research: Application 22-059.  http://www.fda.gov/cder/foi/nda/2007/022059s000_ClinPharmR.pdf. Accessed April 10, 2008) documents lapatinib-induced QT prolongation, noting that administration of lapatinib with food "would be expected to further prolong the QTc interval" a risk factor for torsades de pointe and/or sudden death (Garnett CE, Beasley N, Bhattaram VA, et al. Concentration-QT Relationships Play a Key Role in the Evaluation of Proarrhythmic Risk During Regulatory Review. J Clin Pharmacol. 2008 Jan;48(1):13-8]).

      The authors Ratain and Cohen even less prudently offer a suggestion that even greater cost savings might be achieved by drinking grapefruit juice with food to further boost bioavailability, this despite the large body of literature demonstrating the highly variable effect of grapefruit juice with bioavailability being modulated in either direction due to multiple effects on metabolic enzymes including the hepatic p450 cytochrome system, and intestinal and hepatic drug transport proteins (see Koch et al., above)), with well-documented adverse consequences, possibly also increasing the risk of serious toxicity from other drugs prescribed concomitantly. We simply do not want to add to the erratic and generally adverse interactions from furanocoumarins like the bergamottin component of grapefruit juice. To offer a final cautionary scenario: a patient, following the Retain-Cohen suggestion, consumes reduced dose (250 - 500mg) of lapatinib with a high-fat meal, but for this patient - and possibly for this meal among many others - the predominant fat contribution comes from soy-based fat via soybean, which would in turn deliver high daidzein and genistein isoflavone soy components. But these soy components are CYP3A4-mediated in metabolism -and, unfortunately, lapatinib metabolism, and hence both its safety and efficacy, is also severely CYP3A4-mediated, therefore leading to potential highly adverse drug-food interaction over the p450 hepatic cytochrome enzyme system. In any rational and moral approach to drug administration, we cannot accept that some patients get unlucky by virtue of meal composition. In a fasting state, all patients are created equal.

    A Plea for Consistency

    The TAM-SSRI Lesson

    • But recent developments support our cautionary stance: the results by SK Knox and coresearchers (Knox et al., 2006 ASCO Annual Meeting Proceedings, in J Clin Oncol (2006): Cytochrome P450 2D6 status predicts breast cancer relapse in women receiving adjuvant tamoxifen (Tam)) just reported at the June 2006 ASCO meeting found that in patients that coadminister tamoxifen and an CYP2D6-inhibitory agent such as an SSRI or other inhibitory agent (fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), cimetidine(Tagamet), amiodarone (Cardarone), doxepin (Adapin/Sinnequan), ticlopidine (Ticlid) and haloperidol (Haldol) were tested), had significantly worse time to recurrence(TTR) and disease free survival (DFS), in the real human clinical setting, settling the matter. But that puts many oncologists in the embarrassing position of having countenanced significant adverse impact on patient outcome on the basis of an optimistic stance that, after all, only the potential for harm had priorly been demonstrated, not actual harm; with the Knox findings we now know retrospectively that the potential was real and did translate into adverse impact of patient outcome in terms of both disease recurrence and survival, and so this seriously degrades the value of any optimistic stance on these matters.

    • Indeed, the stance most oncologists took on the above issue - of the potential compromise in the antitumor efficacy of tamoxifen by concomitant administration of SSRI antidepressants - was not only inconsistent, but would appear hypocritical, as the attitude was "the jury is still out" so co-administration should continue.

    • Yet as to comparable potential adverse interactions between oncotherapeutic agents and various agents, the vast amount of which was based solely on in vitro, not in vivo or human clinical data, oncologists typically argue strongly that against co-administration, regardless of here too "the jury being out" (and after all, we have a perfectly good solution to the TAM-SSRI interaction problem: use a NSRI such as the highly effective antidepressant (and hot flash relief) venlafaxine (Effexor).

    Antioxidant Co-Administration with Oncotherapeutics:
    Misreading the Evidence - Lack of Robust Evidence of Harm

    • Similarly, oncologists typically argue strongly against co-administration of antioxidants and oncotherapeutic agents, yet on the balance of the evidence, the preponderance of data suggests a synergistic or at least harmless effect with most high-dose dietary antioxidants and chemotherapy, and claims to the contrary are inconsistent and not supported by the evidence data, in that if antioxidants were in reality a significant threat to the efficacy of standard CT and RT, antioxidant-rich foods like fruits and vegetables would also be prohibited during therapy, no rational oncologist would make such a recommendation (in part because studies have supported the positive benefit of such consumption to overall health and QOL (quality of life)).

    • In addition, there is again an inconsistency and evidence-based research, and our own review, has already challenged this inconsistency from another more critical vantage point: synthetic antioxidants are already in wide-scale use by both medical and radiation oncologists to control the adverse effects of cytotoxic CT treatments. There are several radioprotectant and chemoprotectant agents that are widely used in conventional oncology whose principal mode of activity is antioxidative such as the highly effective and successful amifostine (Ethyol), used as a radio-protective and cytoprotective, mesna (Mesnex) a bladder-cytoprotective, dexrazoxane (Zinecard) a cardioprotective against oncotherapy cardiotoxicity, and pentoxifylline (Trental), a radioprotective used to treat RIF, radiation-induced fibrosis, all antioxidants. The research on metastatic breast cancer of Keith Block and Charlotte Gyllenhaal at the Center for Integrative Cancer Care and University of Illinois (Block & Gyllenhaal, Integr Cancer Ther (2004): Antioxidants and Cancer Therapy: Furthering the Debate), among many others, suggest that patients who received chemotherapy with antioxidant support at their clinic had better outcomes rather than the non-observed interference by antioxidants of conventional CT therapies. This raises a consistency problem for any oncologist who argues that antioxidants should not be co-administered with oncotherapies, but it would appear that comparable conventional antioxidants (all FDA approved for use for their benefits via their antioxidant activity) are coadministered and apparently without adverse interaction or interference.  For example, amifostine, a pharmacological antioxidant used as a cytoprotectant (protecting normal tissues relative to tumor tissue - that is, both as a  chemoprotectant and as a radioprotectant - was reviewed and found to exert protection against mucositis, esophagitis, neuropathy (but not against cisplatin-induced ototoxicity), with no evidence of tumor protection observed (Block KI, Gyllenhaal C.  Commentary: the pharmacological antioxidant amifostine -- implications of recent research for integrative cancer care. Integr Cancer Ther 2005 Dec; 4(4):329-51).

    • Keith Block at the Institute for Integrative Cancer Research and Education and coresearchers recently conducted a systematic review of 19 RCTs on the efficacy of coadministration of antioxidant supplementation with chemotherapy (Block KI, Koch AC, Mead MN, et al. Impact of antioxidant supplementation on chemotherapeutic efficacy: A systematic review of the evidence from randomized controlled trials. Cancer Treat Rev 2007 Mar 14) evaluating Vitamin A, Vitamin C, Vitamin E, melatonin, NAC, ellagic acid, glutathione, and an antioxidant mixture in subjects with predominantly advanced or relapsed disease. They found that none of the trials found any evidence of significant decreases in efficacy from antioxidant supplementation concurrent with chemotherapy, with many of the studies finding that antioxidant supplementation yielded either increased survival times, increased tumor responses, or both, as well as fewer toxicities than controls, although they note that lack of adequate statistical power was a consistent limitation, so that large, well-designed studies of antioxidant supplementation concurrent with chemotherapy are further warranted. See also the review of Moss RW. Should patients undergoing chemotherapy and radiotherapy be prescribed antioxidants? Integr Cancer Ther 2006 Mar; 5(1):63-82) who concluded that "A blanket rejection of the concurrent use of antioxidants with chemotherapy is not justified by the preponderance of evidence at this time" (and similarly for radiotherpy: Moss RW. Do antioxidants interfere with radiation therapy for cancer? Integr Cancer Ther 2007 Sep; 6(3):281-92, concluding that "the preponderance of evidence supports a provisional conclusion that dietary antioxidants do not conflict with the use of radiotherapy in the treatment of a wide variety of cancers and may significantly mitigate the adverse effects of that treatment"). Also Simone CB, Simone NL, Simone V, et al. Antioxidants and other nutrients do not interfere with chemotherapy or radiation therapy and can increase kill and increase survival, part 1.  Altern Ther Health Med 2007 Jan-Feb; 13(1):22-8; Simone CB, Simone NL, Simone V, et al. Antioxidants and other nutrients do not interfere with chemotherapy or radiation therapy and can increase kill and increase survival, Part 2. Altern Ther Health Med 2007 Mar-Apr; 13(2):40-7 who concluded  from their review (since the 1970's) of 280 peer-reviewed in vitro and in vivo studies, including 50 human studies involving 8,521 patients, 5,081 of whom were given nutrients, that comprehensive this evidence base consistently shows that antioxidants "do not interfere with therapeutic modalities for cancer", and that furthermore, it appears that "non-prescription antioxidants and other nutrients enhance the killing of therapeutic modalities for cancer, decrease their side effects, and protect normal tissue", with 15 human studies of 3,738 patients actually suggesting increased survival.

      The subtle and complex issue involved in this arena are demonstrated by the exchange between Brian Lawenda at the Naval Medical Center San Diego and Jeffrey Blumberg at Tufts on the one hand (as per their JNCI article: Lawenda BD, Kelly KM, Ladas EJ, et al. Should supplemental antioxidant administration be avoided during chemotherapy and radiation therapy? J Natl Cancer Inst 2008 Jun 4; 100(11):773-83), and their several respondents. Finally, with respect to the Lawenda JNCI article, it should be noted that (1) it ignores the two reanalyses and reinterpretations of the seemingly negative Bairati study which in fact shows no harm to coadministration of antioxidants and radiation therapy except for patients who also smoke during therapy (see immediately below for full discussion), and (2) the Lawenda article actually found that antioxidants may enhance the effects of chemotherapy as well as diminish its toxicity ("no decrements in tumor response rates or survival rates were observed" they conclude) yet the study abstract counterfactually states that supplemental antioxidants should be discouraged during both chemotherapy and radiation, in contradiction of their own conclusions within the article itself, especially regrettably since virtually all popular media solely read the abstract not the full paper, as did many health professionals themselves, hence leading to a trumpeting of an injunction against coadministration of antioxidants and oncotherapy (chemo and radiation therapy) not supported by the evidence (like the somewhat hysterical and wholly erroneous headline from Randy Dotinga in HeathDay: "Cancer Patients Should Steer Clear of Antioxidants Research - review suggests they may help cancer cells resist chemo, radiation".  We have often remarked on the dangers of lay misinterpretation of complex medical research findings, and of lay and professional reading only article abstracts not the full text, and moreover doing so uncritically, without the skills for methodological appraisal, and this adds another case in point.     

    • Much of the motivation for a prohibition against coadministration of antioxidants with radiation therapy comes the widely cited study of such coadministration in head and neck cancer patients conducted by Isabella Bairati and colleagues (Bairati I, Meyer F, Gélinas M, et al. A randomized trial of antioxidant vitamins to prevent second primary cancers in head and neck cancer patients. J Nat Cancer Inst. 2005;97:481-488) which gave (synthetic)  alpha-tocopherol and beta-carotene supplements to patients at high risk of second primary cancers.  Higher rates of second primary cancers, along with more recurrences, were found in the supplementation group, with higher all-cause mortality and a trend towards higher cancer-specific mortality during supplementation. These negative findings were disseminated and cited widely in the professional literature and in the popular media, and to this day account for much of the common and pervasive belief in the oncology and radiology communities that antioxidant coadministration with chemotherapy or radiotherapy must be avoided as such practice may lead, as per the study results, to actual harm and effect outcome adversely.

      Unfortunately, what the professional communities and the lay public failed to realize - even to this day - was that the findings are in fact in error:  analysis of Bairati’s study population by Francois Meyer at Laval University and coresearchers established that the observed excess recurrences were restricted to only those patients on supplementation who continued to smoke throughout radiation therapy, suggesting that the efficacy of radiation therapy was reduced only by the combined exposures, since for nonsmokers receiving supplements, the hazard ratios hovered near one so that no there was excess risk of mortality compared to the placebo group and hence no adverse effect of supplementation (Meyer F, Bairati I, Fortin A, et al. Interaction between antioxidant vitamin supplementation and cigarette smoking during radiation therapy in relation to long-term effects on recurrences and mortality: a randomized trial among head and neck cancer patients. Int J Cancer. 2008;122:1679-1683).  Thus patients who either do not smoke quit smoking during therapy may accrue the benefits of antioxidant supplementation for the reduction of side effects, and without affecting therapeutic efficacy of the radiation therapy.

      The same team of researchers undertook another reanalysis of the Bairati study which found, against the putative negative interpretation of  the study, that those patients with the highest dietary intake of beta-carotene actually had significantly fewer radiation side effects, and that furthermore those patients with the highest plasma levels of beta-carotene also had a 33% reduction in local recurrences, clearly not only not adversely affecting therapeutic efficacy of the radiation therapy, but also providing improved outcome via recurrence reduction (Meyer F, Bairati I, Jobin E, et al. Acute adverse effects of radiation therapy and local recurrence in relation to dietary and plasma beta carotene and alpha tocopherol in head and neck cancer patients. Nutr Cancer. 2007;59(1):29-35).  When the antioxidant was allowed to do its work without the ill effects of tobacco, its ability to reduce side effects without affecting therapeutic efficacy was shown. Thus, a leading study put forth to suggest that antioxidants provide a protective shield to tumors during radiation therapy is found (in the absence of concurrent smoking) to actually establish no such thing, but rather to suggest that coadministered antioxidants and radiotherapy not only protect patients from therapy-induced side effects, but also benefit outcome by reduction of recurrence (also concluded by numerous other studies, including the recent review of Paul Okunieff and colleagues at the University of Rochester Medical Center: Okunieff P, Swarts S, Keng P, et al. Antioxidants reduce consequences of radiation exposure. Adv Exp Med Biol 2008.:165-78).
       
    • A more recent (2008) systematic review of 33 RCTs on the effect of concurrent antioxidant supplementation on chemotherapeutic toxicity (Block KI, Koch AC, Mead MN, et al. Impact of antioxidant supplementation on chemotherapeutic toxicity: A systematic review of the evidence from randomized controlled trials. Int J Cancer 2008 Jul 11) evaluated Vitamin A, Vitamin E, melatonin, NAC, ellagic acid, glutathione, L-carnitine, selenium, CoQ10, and an antioxidant mixture in subjects with predominantly advanced or relapsed disease. It found that the majority (24) of the studies demonstrated evidence of decreased toxicities from antioxidant-chemotherapy coadministration, nine studies reported no difference in toxicities, with only 1 study on Vitamin A reporting a significant increase in toxicity in the antioxidant group. In addition several (5) studies found that the antioxidant group completed more full doses of chemotherapy or had less-dose reduction than control groups. And although statistical power and poor study quality were concerns with some studies, the authors concluded that there is evidence antioxidant-chemotherapy coadministration holds potential for reducing dose-limiting toxicities, and without without affecting therapeutic efficacy of the therapy.

      In sum, just as there can be no blanket disjunction against all coadministration during chemotherapy or radiation therapy, neither however can there be a blanket inclusion, and each CAM agent and intervention must be critically assessed, as witnessed are detailed coverage above of several specific natural agents that require caution against coadministration by virtue of potentially adverse interactions with oncotherapies.  

    • Context-Dependent Guidance
      Guidance may be stratified and distinguished by the context:
      (1) in the advanced refractory and metastatic disease context, many potentially beneficial antitumor agents, both conventional and CAM, may be countenanced given the well known progress of the disease and the typically stark prognosis;
      (2) in non-metastatic / non-refractory contexts, the imperative for such use is muted and caution can be weighed and balanced; and
      (3) in a disease-naive context - as chemopreventive aid - individual decision can be less constrained as at least the potential for adverse interaction is not present.

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