Due to the complex and specific nature of oncology management, many patients do not seek naturopathic support during their chemotherapeutic treatment, however often require assistance once chemotherapy has been completed. Patients regularly report significant fatigue and poor immunity following chemotherapy, conditions which are well supported with naturopathic care. This case illuminates the profound improvements that can be achieved using minimal intervention.

Initial consultation

A 47- year-old female presented with persistent, constant fatigue and frequent infections following chemotherapy for an oestrogen receptor positive (ER+), progesterone receptor positive (PR+) and human epidermal growth factor receptor 2 positive (HER2+) invasive carcinoma of the breast. She had received one year of chemotherapy treatment including weekly intravenous Paclitaxel, and three weekly Pertuzumab and Trastuzumab. The patient responded positively to treatment, which also included a mastectomy and was maintained on Tamoxifen.

A case history revealed:

- Energy levels rated 4-5/10 including a 3 pm slump;

- Poor sleep – achieving 5-6 hours of sleep per night, with difficulty falling asleep
  and trouble returning to sleep if woken in the early morning (4 am);

- Waking with no energy;

- Low mood and mood swings – worsening in the past 3 months;

- Irritability – emotions not matching the situation;

- Stress intolerance – feeling like there is no ‘buffer zone’ – from 0 to 8/10
  very easily;

- Hot flushes – approximately 12 throughout the day and night;

- Weight gain of 13 kg which was not responding to diet and lifestyle changes;

- Ulcerative colitis (UC) – maintained on mesalazine;

- Frequent mouth ulcers;

- 2-3 bowel movements daily, formed, but sticky recently;

- Cravings for savoury foods, sugar and carbohydrates;

- Anxiety – socially, resulting in exhaustion post-socialising;

- Regular sickness – feels like every week is out of action for a few days;

- Joint pain – every joint; can barely walk in the colder months;

- Recent urinary tract infection (UTI), which quickly manifested as a kidney
  infection requiring antibiotic treatment, which was successful;

- Dry mouth, regardless of fluid intake;

- Low libido;

- Overall good quality diet, however high in refined carbohydrates, simple sugars
  and caffeine.

Previous testing revealed:

- Alkaline phosphatase 116 U/L (30-110)

- Lymphocytes 4.1 10⁹/L (1.0-4.0)

- No active gastrointestinal inflammation evident on colonoscopy or endoscopy,
  however evidence of UC present.

Current medications and supplements:

- Mesalazine 1.2 g. Dose: 2 tablets twice daily;

- Tamoxifen 20 mg. Dose: 1 tablet daily;

- Calcium carbonate 1000 mg. Dose: 1 tablet daily;

- Probiotic (unknown strains). Dose: 1 capsule daily;

- An immune modulating blend of Medicinal Mushrooms, herbs and cofactors
  containing Lentinula edodes (Shiitake) 1.5 g, Ganoderma lucidium (Reishi)
  750 mg, Trametes versicolour (Turkey Tail) 650 mg, Camellia sinensis
  (Green Tea) 2 g, and co-factors. Dose: 1 capsule twice daily.

- N-acetylcysteine 1000 mg daily;

- Omega 3 fatty acids; only when remembers;

- Vitamin C powder (dose unknown); if feeling run down;

The patient also had her own magnesium powder supplement, which she was not currently taking.

Initial prescription

The initial prescription was aimed improving the patient’s energy levels, supporting immune function and improving sleep quantity and quality. Treatment commended slowly as the patient reports a sensitivity to herbal medicine and pharmaceutical medicine and was wary of interactions with her current medications. All medicines were assessed for interactions and estrogenic activity with the herbal medicine supplier’s database. The patient also had the prescription assessed by her pharmacist, who although was not supportive, could see no negative interactions.

- A herbal liquid containing Eluetherococcus senticosus (Siberian Ginseng)
  50 mL, Rhodiola rosea (Rhodiola) 40 mL, Salvia officinalis (Sage) 30 mL,   
  Astragalus membranaceous (Astragalus) 60 mL, Rosemarinus officinalis    
 (Rosemary) 30 mL. Total: 210 mL. Dose: 7.5 mL taken twice daily with breakfast
  and lunch.

- A magnesium, glutamine and co-factors powder for mineral repletion and gut
  health containing glutamine 2 g, magnesium (as citrate) 310 mg, taurine 1.5 g,
  and co-factors. Dose: 1 (8 g) scoop once daily before bed;

- Patient’s own vitamin c. Dose: 1000 mg twice daily;

- Probiotic containing Lactobacillus rhamnosus HN001 5.0 billion CFU,
  Lactobacillus plantarum Lp-115 3.0 billion CFU, Lactobacillus gasseri Lg-36 1.0
  billion CFU, Lactobacillus reuteri RC-14 1.0 billion CFU, Lactobacillus rhamnosus
  GR1 1.0 billion CFU, Vaccinium macrocarpon (Cranberry) fresh fruit 25 g. Dose:
  take 1 capsule daily with food;

Continue Medicinal Mushroom capsule, N-acetylcysteine and
calcium supplements.

Dietary and lifestyle advice included:

- Reduce refined carbohydrate intake – replace with vegetable options; for
  example, cauliflower rice, cauliflower pizza bases.

- Slowly introduce fermented foods; miso, sauerkraut, kim chi.

3 week follow-up

The patient reported feeling ‘incredible’. She reported an improvement of energy to levels that she had not experienced for years, rated 10/10. The patient reported ‘feeling like a normal person’. She had experienced an initial worsening of hot flushes, loose stools and poor sleep, all of which subsided with a reduction in the dose of herbal liquid to 2.5 mL daily. She reported 10 hot flushes daily. The patient’s anxiety symptoms were 0/10, mood was improved and she had missed getting a cold which the rest of her family suffered from. She had made the recommended changes to her diet and lost 1.5 kg. She was also walking briskly for 1 hour daily. The patient had no mouth ulcers, and an improvement in her dry mouth, however no changes to her libido, joint pain or sleep. She also reported a normalisation of her appetite, which had previously been insatiable. Her prescription was altered to address the remaining hot flushes, improve sleep quality, support gut health and reduce joint inflammation. All treatments were assessed with the herbal medicine supplier’s database along with a review of the medical literature prior to prescribing.

The prescription was updated to the following:

- A herbal liquid containing Cimicifuga racemosa (Black Cohosh) 30 mL,
  Astragalus 60 mL, Siberian Ginseng 40 mL, Rhodiola 40 mL, Calendula officinalis
 (Calendula) 40 mL. Total 210 mL. Dose: take 2.5 ml daily in the morning;

- A herbal liquid containing Zizyphus spinosa (Zizyphus) 40 mL,
  Eschscholzia californica (California Poppy) 30 mL, Withania somnifera
 (Withania) 25 mL. Total 105 mL. Dose: take 2-5 mL before bed.

- A nutritional powder for gut healing containing L-glutamine 2.2 g, Larix
  occidentalis (Larch arabinogalactan) 2.0 g, zinc (as bisglycinate) 15 mg,
  Aloe barbadensis (Aloe Vera) 5.0 g, Boswellia serrata (Boswellia) 1.5 g,
  vitamin A 1.4 mg, and vitamin D 12.5 µg. Dose: take 2 scoops (7.7 g) twice daily
  in water;

- An omega 3 capsule containing Eicosapentaenoic acid (EPA) 360 mg, and
  Docosahexaenoic acid (DHA) 240 mg. Dose: 2 capsules daily with meals;

- Continue magnesium as per previous prescription.

10 week follow-up

The patient reported that she was sleeping better since commencing the night-time herbs. She was waking feeling energised in the morning and had ceased using the daytime formula regularly, and now used only as needed. Her stress levels improved from 8/10 to 3/10. Hot flushes had reduced to 4 times daily. Joint pain was improved, which was unexpected with the change to cooler weather, which usually exacerbated her pain levels. The patient had recently come down with influenza which coincided with looser bowel movements and an increase in mouth ulcers. She was experiencing no anxiety and a significant improvement in mood, reporting less irritability, despondence and apathy, with an improvement
in motivation.

Her prescription was continued with the addition of the following:

- Use glutamine and co-factors powder as prescribed, but swish in mouth
  before swallowing;

- Adopt a Mediterranean-style diet;

- Include meditation or relaxation in the evening before bed.

Clinical reflections

Oncology can be a difficult area to manage for patients and practitioners alike. Concerns around treatment interactions are valid, and should not be taken lightly. This case is an example of how when taken slowly, and with careful consideration, the patient can achieve heroic results with minimal intervention. The case also presented a valuable opportunity for practitioner education around herbal safety in oncology. Utilising practitioner support teams and medical literature ensured confidence for the patient as well as the practitioner and resulted in a positive outcome.