According to Harrisonâï¿½ï¿½s Principles of Internal Medicine, 216,000 women developed breast cancer in the US in 2004, and 40,000 died, making the disease the most common malignancy (other than skin) among women. (1) Though surgery can cure in the range of 50% of those diagnosed initially with localized disease, for patients with evidence of distant spread, breast cancer remains ultimately incurable despite advances in chemotherapy, hormonal intervention and blockade and targeted therapies such as Herceptin. The five-year survival for women with evidence of metastatic disease at the time of diagnosis is around 14%, and in the conventional medical world, even these survivors will eventually die of their cancer. In the DeVita textbook, Cancer: Principles and Practice of Oncology, the authors report an average lifespan for women diagnosed with metastatic breast cancer of 2-3 years, with some variability. (2) Poor prognostic indicators include an incomplete or short-lived response to prior therapy; negative hormone receptor status; involvement of a major organ like the liver or brain; and multiple sites of involvement.
Patient FK: A 19-Year Survivor
Patient FK is a 71-year-old woman who had been in good health when in mid-1984, she first noticed a right breast mass. She was referred for a breast biopsy, which proved to be benign. However, within a month of the procedure, her health began to decline rapidly: she developed gradually worsening fatigue, paresthesias and chronic wheezing. Her internist reassured her, telling her “not to worry.”
After FK suffered a gradual weight loss in early 1985, in April her right breast and axillary region suddenly enlarged, turned red and painful. Her physician, assuming she had an infected breast, prescribed antibiotics, but the breast swelling only worsened and in August 1985 she was admitted to a local hospital for evaluation. On exam, FK was found to have a malignant appearing 8 by 8 cm mass, confirmed as cancer by biopsy. Hormone receptors were negative.
The tumor was thought far too large for resection, so in September 1985, FK began radiotherapy to the chest wall, eventually receiving a total of 5100 rads. After completing treatment, she underwent a right modified radical mastectomy, with the pathology report describing infiltrating ductal carcinoma of the breast, involving 17/17 axillary nodes at all levels.
Shortly after surgery, FK began chemotherapy with CMF, a protocol she continued for the next two years. In August 1987, while still on treatment, she developed pain in her ribs and sternum. A bone scan in September 1987 documented increased activity in the sternum and two right anterior ribs consistent with metastatic disease. X-ray studies confirmed probable sternum metastases.
Since she had developed recurrent disease while receiving aggressive chemotherapy, FK began investigating alternative approaches to cancer. She learned of my work and first came to my office in December 1987, while she still continued chemotherapy. At that time, she complained of fatigue and severe depression, particularly worse after each dose of chemotherapy.
After beginning her nutritional therapy in late 1987, she proved to be a very determined and compliant patient. Initially, because her oncologist had so frightened her with his dire prognosis, she continued on single agent chemotherapy, methotrexate. Since she had already failed the CMF regimen which included the drug, this approach didnâï¿½ï¿½t make much sense to me, but her oncologist, who already announced her disease had reached a terminal phase, apparently hoped the treatment might extend her life a few months. Usually, we discourage patients from beginning our program if they will be continuing chemotherapy, but in this case, I agreed to the combined approach. Once on her nutritional regimen, FK reported a dramatic improvement in her general health, with resolution of her bone pain and depression. She continued chemotherapy intermittently for five years with methotrexate and later vincristine, before finally giving it up entirely and continuing only on my therapy.
For many years, she avoided radiographic testing until May 2001, when a bone scan showed that the previously evident lesions had resolved completely. The official reports âï¿½ï¿½No definite abnormal uptake of radiotracer suggesting skeletal metastasis.âï¿½ï¿½ Today, 19 years after her recurrence, and 21 years since her original diagnosis of aggressive disease, she remains in excellent health with no evidence of cancer.
Although her course was initially complicated because she continued chemotherapy, at her oncologistâï¿½ï¿½s insistence, any drug effect can be discounted since she had developed metastatic disease while completing a two year course of chemotherapy. Also, chemotherapy, no matter the type, does not cure metastatic breast cancer into the bone. To put this unusual survival in perspective, in a comprehensive evaluation of women diagnosed with invasive breast cancer, all receiving conventional treatment, Elder reports a 2.4 year median survival after diagnosis of bone metastases. (3)
Patient IK: A 16-Year Survivor
Patient IK is a 64-year-old woman with a strong family history of breast cancer. She had previously been in good health when in the fall of 1986, routine mammography revealed a suspicious mass in the left breast, confirmed by biopsy as ductal carcinoma in situ. Although her surgeon suggested a modified radical mastectomy, IK insisted a lumpectomy be done. The surgeon agreed, and removed the cancerous tumor. Since she had no evidence of metastatic disease, her doctors did not recommend additional adjuvant treatment.
She subsequently did well until July of 1989, when her physician detected a mass in the right breast. She underwent lumpectomy as well as excision of a 3 cm right axillary mass that proved to be a poorly differentiated adenocarcinoma, estrogen and progesterone receptor negative, invading and largely replacing the adjacent lymph node. After surgery, an abdominal ultrasound revealed a density on the right lobe of the liver consistent with metastatic disease. A needle biopsy of the hepatic lesion confirmed metastatic carcinoma, and a bone scan showed âï¿½ï¿½multiple focal areas of increased activity in the spine consistent with metastatic carcinoma.âï¿½ï¿½
IK then began chemotherapy with CAF, a very aggressive protocol which she tolerated poorly. In late 1989, after completing three cycles, she refused further treatment and for several months, she did nothing before visiting Stanford in the spring of 1990 for a second opinion. There, after reviewing the previous biopsies and scans, the physicians concurred with the diagnosis of metastatic disease to the liver. The Stanford note reports âï¿½ï¿½The diagnosis is confirmed and the liver involvement has been documented by the Stanford Pathology Laboratory.âï¿½ï¿½
Her doctor at Stanford recommended she immediately resume chemotherapy with CAF, but once again, IK refused to consider further orthodox therapy. Instead, after learning of my work, she decided to pursue my program and was first seen in my office in April of 1990.
She was quite ill at the time, suffering chronic pain in her liver. After returning home and beginning her regimen, the liver pain was so severe she required MS Contin for comfort. She also suffered fatigue and malaise lasting many months, before she finally began to improve. When I saw her for a return evaluation in May 1991 - a year after she had begun her nutritional protocol - she felt much stronger and her abdominal pains had largely resolved. Unfortunately, she began to feel so well that without my knowledge, she subsequently discontinued her protocol, assuming she was “cured.” In early July 1991, she called me very distraught, having just suffered a grand mal seizure, and admitted she had been off her protocol for several months. A CT scan of the brain revealed a high-density epidural mass in the left sphenoidal ridge and a small low density area in the right temporoparietal region. The radiology report reads âï¿½ï¿½Both areas were heterogeneously enhanced with contrast medium and appear to be metastatic brain lesions.âï¿½ï¿½
Her doctors immediately recommended radiation to the brain, which IK refused. Instead, she resumed her full nutritional program with renewed dedication, quickly improved and never had another seizure. Follow up CT scans of both the head and abdomen in April 1992, less than a year after her recurrence, were completely normal âï¿½ï¿½ the previously noted liver and brain tumors were gone. The report of the head CT reads âï¿½ï¿½There is no mass or mass effectâï¿½¦There is no evidence of metastatic diseaseâï¿½¦Normal CT scan of the head.âï¿½ï¿½ The summary of the abdominal scan states: âï¿½ï¿½Normal CT scan of the abdomen.âï¿½ï¿½
Since that time, IK has had an up and down history on my program, with periods of good compliance and periods of less than good compliance. I havenâï¿½ï¿½t seen her in my office in some years, but heard from friends that she is still doing well and still taking enzymes. Our last formal contact with her was in October of 2005, when she appeared to be doing fine, 15 years after her diagnosis of terminal metastatic breast cancer.
Her course with such terrible disease is certainly unusual. IK also served as her own âï¿½ï¿½control;âï¿½ï¿½ when she followed the program she did well, and when she didnâï¿½ï¿½t comply, the cancer came back with a vengeance. The disease then completely regressed when adherence to therapy improved.
We usually tell new patients coming to us with a history of metastatic cancer that they need to follow their nutritional regimens indefinitely, and must never assume they are completely free and clear. Dr. Isaacs and I think of cancer as a chronic degenerative disease, akin to diabetes, that can be managed successfully for years as long as patients follow their diet and take their enzymes. When a patient falls off the wagon, as in this case, cancer can return and cause havoc. Renewed dedication to the treatment can usually get the situation back under control.
Regardless of her compliance lapses, IKâï¿½ï¿½s survival is extraordinary. As the medical literature documents, breast cancer, when metastatic to either the brain or liver, is a deadly disease. In a series of patients with brain metastases specifically, Lentzsch et al report a median survival of 23 weeks for those with more than one lesion, despite aggressive conventional treatment. (4) In a group of patients with at least one lesion receiving supportive care only, the authors describe a median survival of 5 weeks.
Eichbaum et al studied a group of 350 women with breast cancer that had metastasized to the liver. (5) The authors describe a median survival, regardless of the conventional treatment given, of 14 months, somewhat better than the numbers for brain metastases, but still dismal.
In this case, IK had evidence of liver, brain and bone metastases, as deadly a combination as can be imagined.
Patient AR: A 16-Year Survivor
Patient AR is a 72-year-old woman who had generally been in good health when in July 1990, she detected a left breast mass. Mammography revealed, as the official report states, âï¿½ï¿½several areas of increased density with the upper outer aspect of the left breast which appear markedly asymmetric as compared to the right breast and which have the appearance of mass densities with irregular margins.âï¿½ï¿½ After an ultrasound confirmed a 1.8 cm density in the left breast, the patient was scheduled for a lumpectomy.
A routine preoperative chest X-ray showed nothing, but a chemistry blood screen demonstrated markedly elevated liver functions tests with an alkaline phosphatase of 154 (normal less than 140), AST of 89 (normal less than 50) and a ALT of 138 (normal less than 55). But an abdominal ultrasound revealed a normal liver with âï¿½ï¿½no metastases.âï¿½ï¿½ Then in September 1990, AR underwent excisional biopsy (lumpectomy) for what proved to be a much larger tumor than had been expected based on the mammography and ultrasound findings, measuring 4 X 3 X 3.2 cms. The mass, which could not be completely removed, was found consistent with a well-differentiated mucinous adenocarcinoma of the breast, estrogen and progesterone receptor positive. The pathology report states ominously âï¿½ï¿½The lesion extends to the margins of the specimen submitted on the lateral and undersurface.âï¿½ï¿½
After a bone scan revealed only arthritic changes, AR met with her surgeon who insisted a mastectomy was now necessary since residual cancer remained in the breast. He suggested that after the procedure, she undergo a course of intensive multi-agent chemotherapy. AR also met with a radiation oncologist and a medical oncologist, who both agreed that because of the size of the tumor, she required, after surgery, radiation followed by chemotherapy.
However, AR, as she later was to tell me, had seen âï¿½ï¿½too many people cut to pieces and poisoned only to die,âï¿½ï¿½ for her to agree to any further conventional treatment. She refused additional surgery, chemotherapy, and radiation, and instead investigated alternative approaches. After learning of my work through a friend, she first consulted with me in October 1990 and thereafter followed her program with great determination. As an quick benefit, within weeks her liver function tests normalized.
AR followed her program diligently for some eight years, until 1998, when I last saw her in my office. During this time, she refused all testing other than routine blood analysis, saying she wouldnâï¿½ï¿½t change her therapy regardless of what the studies showed. Sixteen years out from her original diagnosis, she is in excellent health, active with various activities and hobbies. She follows components of the program, as much as her finances allow, and still refers patients to me regularly.
AR, though lacking evidence of metastatic spread at the time of her original diagnosis, certainly represents a remarkable success. The size of the original tumor, coupled with the fact that residual cancer remained after the original lumpectomy, portended a troubling prognosis, even had she agreed to the proposed chemotherapy and radiation. On my program, however, she has enjoyed a healthy and cancer free life.
I included her because we have in our practice a number of women who despite evidence of substantial residual cancer in the breast after a positive biopsy, refused any further conventional intervention, instead choosing only our program for treatment. Though these women have generally done very well for very long periods of time âï¿½ï¿½ 16 years in the case of AR âï¿½ï¿½ we no longer accept patients with localized breast cancer who do not proceed with recommended surgical procedures. Our decision has not been dictated by a negative clinical experience, but rather the extraordinarily hostile legal environment that exists for alternative practitioners such as ourselves. Standard-of-care criteria require a woman like AR undergo further aggressive surgery, and the world would need a consciousness shift before we would consider taking on such patients again.
Patient VE: A 14.5-Year Survivor
Patient VE is a 62-year old woman with had a long history of fibrocystic breast disease, first diagnosed when she was 19 years old. Thereafter, her doctors followed her closely with frequent mammography, and two biopsies showing benign changes.
In 1991, mammography again indicated dense fibrocystic breasts as well as a new âï¿½ï¿½1 cm nodular density in the upper and axillary portions of the right breastâï¿½¦This contains internal microcalcifications in a diffuse pattern, and represents a new findingâï¿½¦.âï¿½ï¿½ Her doctors recommended biopsy, which VE, already interested in alternative approaches, refused, instead choosing to follow a nutritional program under the supervision of a local practitioner. However, repeated mammography in March 1992 showed a worsening picture:
Once again, I note small nodule in the upper outer right breast, in association with many microcalcifications. Number of microcalcifications has increased slightly during the interval.
At that point, in the spring of 1992, VE underwent needle biopsies of eight lesions, four of which proved positive for ductal carcinoma. Since she had diffuse disease throughout the breast, her surgeon insisted she needed mastectomy. However, the patient decided to refuse all further surgery and any other conventional treatment, instead opting for our regimen.
When VE first consulted me in 1992, she had, on exam, very dense nodular breasts but seemed otherwise in good health. During our lengthy initial interview, I encouraged her to reconsider surgery, which for early stage breast cancer can often be curative. In a calm and determined way she explained her decision to refuse disfiguring surgery or toxic conventional treatment, whether I chose to be her doctor or not, so I agreed to treat her.
She subsequently followed her regimen diligently, and over the years has done extremely well, though declining all further testing. Today, she adheres to a maintenance protocol and appears to be in excellent health, now 14.5 years from her biopsy diagnosis.
As in the case of AR, Dr. Isaacs and I most likely would not agree to treat a patient like this today. The legal climate for alternative medicine remains repressive, the power and authority of conventional medicine, despite its well documented and rather glaring limitations, is formidable. However, I am gratified by the success of patients AR and VE, and the others like them in our practice, who were able to avoid all aggressive surgery as well as toxic drug and radiation treatments. They still have their breasts, their lives, and their health.
Patient BV: A 15-Year Survivor
Patient BV is a 67-year-old woman who had been in good health when routine mammography in October of 1991 revealed a suspicious breast mass. In late 1991 she underwent biopsy and lumpectomy, with removal of a 2.1 cm. tumor confirmed as in situ and infiltrating ductal carcinoma. Though no nodes were sampled, a bone scan in December 1991 as part of routine follow-up testing demonstrated increased uptake in the right proximal femur. An MRI in January 1992 documented a lesion on the right greater trochanter consistent with metastatic disease. The official report reads âï¿½ï¿½A solitary lesion is noted distal to the right greater trochanterâï¿½¦most likely representing a metastatic lesionâï¿½¦âï¿½ï¿½
The patient did meet with an orthopedic surgeon who suggested a course of aggressive surgery with hip replacement followed by radiation to the hip. Her breast surgeon insisted BV proceed with mastectomy and subsequent radiation to the chest wall. However, after learning of our approach, BV refused all further conventional interventions, instead choosing to proceed with my treatment.
When I first saw BV in early 1992, she reported severe fatigue and chronic right hip pain, severe enough that she had gone on disability from her job. After beginning her nutritional regimen, she proved to be a very determined, compliant patient. During her first months on therapy, she suffered migratory aches and pains, particularly severe in the right shoulder and hip, but these gradually resolved. In fact, after a period of some months she felt so well she returned to work full time.
Repeat bone scans in May 1992 âï¿½ï¿½ five months after BV began her treatment with me âï¿½ï¿½ showed, according to the report, âï¿½ï¿½No definite evidence of metastatic disease.âï¿½ï¿½ A follow-up scan in June 1993 was again clear, and today, nearly 15 years after she first consulted me, BV remains compliant with her full regimen, and disease free.
Her case is very straightforward. At the time of diagnosis, a bone scan and MRI documented a large tumor in her hip that regressed while she followed only her nutritional program.
Elder et al report a median survival of 2.4 years for women with breast cancer metastatic to bone (3), somewhat better statistics than for those diagnosed with brain or liver metastases. However, these numbers reference patients aggressively treated with conventional modalities such as surgery, chemotherapy and radiation, all of which BV refused.
Patient GX: A 9-Year Survivor
Patient GX is a 70+ woman with a family history pertinent for both colon and breast cancer. She had been in good health when in 1986, after a suspicious mammography, a biopsy confirmed infiltrating ductal carcinoma. She underwent right mastectomy, and three nodes were found infiltrated with metastatic cancer. She subsequently completed a six-week course of radiation to the chest wall, but received no chemotherapy. She did begin tamoxifen.
In early 1989, after she developed rectal bleeding, sigmoidoscopy revealed a 2 cm lesion in the sigmoid colon that was biopsied and found consistent with moderately differentiated adenocarcinoma. Prior to the planned colon surgery, CT scans showed no abnormalities in the abdomen, but a lesion in the lower right lung not evident on prior X-rays. The following day, the patient underwent exploratory laparotomy and resection of the lower sigmoid colon for what proved to be Dukesâï¿½ï¿½ C disease, meaning the cancer had spread into regional lymph nodes. At that time, the lung finding was discounted as insignificant.
GX then completed six weeks of chemotherapy with 5-FU, followed by six weeks of radiation to the lower abdomen, then another six weeks of 5-FU. In addition, she continued on tamoxifen for her previously diagnosed breast cancer. Certainly, at this point, GX faced potential disaster, with two different cancers, each metastatic to local lymph nodes âï¿½ï¿½ a poor prognostic indicator for either. But she actually did fairly well, with subsequent CT scans confirming that the solitary pulmonary nodule had stabilized. In 1996, after she had been on tamoxifen for ten years, her doctors suggested the drug be discontinued, however a year later, in March 1997, a routine chest X-ray showed several new lesions. The radiology report describes âï¿½ï¿½Suspicion of right lung nodules as aboveâï¿½¦a CT scan is recommended.âï¿½ï¿½
A CT scan in April 1997 revealed âï¿½ï¿½Several 1 cm or smaller non-calcified pleural based lung nodules are noted on todayâï¿½ï¿½s examination in the region of the right upper and lower lobesâï¿½¦âï¿½ï¿½
Her surgeon, a long time friend, told GX she had metastatic disease that might have originated from either the breast or colon primaries. He did not advocate for biopsy of the lung lesions since he felt the findings were clearly indicative of cancer. Nor did he press the case for additional conventional treatment when GX made it clear she would never agree to such an approach again. She had already learned of our work, and had chosen to proceed with us.
I first saw GX in my office in April of 1997, shortly after her diagnosis of recurrent disease. A determined, compliant and dedicated patient, I donâï¿½ï¿½t think she has missed a supplement in nine and a half years. And the results have been gratifying; a chest X-ray in April of 1998, a year after she had begun her nutritional program, showed no change in the left nodular density, but resolution of a right lower lung lesion and partial regression of a third right lower lobe nodule. In March of 1999, after GX had completed two full years of treatment, the report of a chest x-ray describes âï¿½ï¿½Clear lungs.âï¿½ï¿½ All the previously noted lesions were gone.
After those clear scans, GX continued doing well. In 2004, seven years after beginning our therapy, mammography revealed calcifications and nodularity in the left breast that on review, had been present on earlier studies dating back to 1993. After biopsy confirmed carcinoma, I agreed that she should proceed with mastectomy since the left breast had been problematic for more than a decade.
The breast contained a very small, 0.3 cm area of carcinoma, with no lymph node involvement. I donâï¿½ï¿½t believe this to have been a new lesion, but suspect her breast was so dense and fibrotic, with multiple long standing calcifications, that the blood supply to the area had probably been compromised, allowing this small cancer to exist though her metastatic disease resolved. I have made some changes in her protocol, which she continues to follow faithfully. Two years later, now nine and a half years since her diagnosis of metastatic disease, she continues doing well.
I have decided to include GX among my breast cancer survivors, though ultimately we donâï¿½ï¿½t know whether the lung lesions were breast or colon in origin. In either case, such spread invariably proves fatal, usually quickly. This patientâï¿½ï¿½s long term survival, coupled with radiographic evidence of tumor regression while following her nutritional protocol, certainly demonstrate a rather remarkable course for what would normally be a deadly situation.
Patient EZ: A 7-Year Survivor
In July 1987, after Patient EZ first noticed a left breast mass, she underwent first a needle biopsy confirming carcinoma, then a modified radical mastectomy. The pathology report describes mixed colloid carcinoma and intraductal and infiltrating duct carcinoma, with 1/7 nodes positive for malignancy. A metastatic work-up, including a bone scan, was negative. When estrogen receptor studies came back positive, she started on tamoxifen.
EZ did well until September 1988 when routine blood testing revealed an elevated CEA at 14. A CT scan showed two lesions in the liver, and a bone scan demonstrated a right rib lesion, all thought consistent with metastatic disease.
In November 1988 EZ began chemotherapy with CMF, which she tolerated poorly. After six cycles, a repeat abdominal CT scan in April 1989 showed worsening disease. Though the previously noted two hepatic lesions remained unchanged, the radiologist noted a third new lesion, 2 cm in diameter. Since her disease had progressed, her oncologist added vincristine to the regimen, but EZ suffered such severe side effects, including debilitating nerve pain, she decided to discontinue all further chemotherapy. At that point, she was told to consider calling in hospice.
Instead, EZ began looking into other approaches, learned of our treatment and first consulted with me in June 1989. After returning home, an abdominal CT scan before she began her nutritional regimen revealed that the liver disease had only worsened despite vincristine added to the chemotherapy mix:
There are several low attenuation lesions about the liver, the largest measuring 3 cm. In the lateral segment of the left lobe of the liver. This lesion appears enlarged since the prior examination. Additionally, a new lesion is noted about the right lobe of the liver. These likely represent metastatic disease.
Subsequently, EZ pursued her program with great dedication. Her local oncologist agreed to follow her since she lived some distance from our office, and after she had completed nearly a year on her protocol, a CT scan of the abdomen in April 1990 revealed significant improvement as documented in the written report:
Comparison is made to the prior examination on 7/12/89. Since then, the metastatic lesions in the liver have decreased slightly in size. The low attenuation lesion in the medial segment of the left lobe now measures 2 cm in diameter as compared to 3 cm on the previous examination. That in the anterior segment of the right lobe now measures 2 cm as compared to previous measurement of 2.5 cm in diameter. No new lesions are identified.
A bone scan in November of 1990 showed resolution of the previously noted rib lesion:
Comparison is made with the patientâï¿½ï¿½s last similar examination performed in October 1988. The only substantive interval change is the apparent resolution of an inferior right rib lesionâï¿½¦
EZ thereafter continued on her nutritional protocol and in April 1991, nearly two years after beginning her program, a CT scan revealed continued improvement:
Multiple small liver lesions most of which measure less than 5 mm in diameter in the medial segment of left lobe as well as anterior and posterior segments of right lobe.
A CT scan 14 months later, in June 1992 âï¿½ï¿½ after she had completed three years of treatment with us - demonstrated that the largest tumor, which previously had been solid, now appeared to be cystic:
Three hypodense hepatic lesions remaining, the largest of which is located in the posterior segment of the right lobe of the liver, measuring approximately 1 cm in diameter, and has the CT characteristics of a simple cyst. The other hepatic lesions are smaller on the current study compared with the prior study (of 4/5/91).
However, during the summer of 1993, EZ âï¿½ï¿½ after enjoying excellent health for four years while pursuing her nutritional program âï¿½ï¿½ reported gradually worsening fatigue. An ultrasound of the liver in July 1993 revealed new progression of the liver lesions, with one now measuring 7.5 cms in diameter.
The sudden worsening I find perplexing even today, years later. Over time, as patients improve, in some cases as cancer becomes less frightening, compliance can falter. As best as I could tell, EZ seemed to be compliant. I do know that her doctor, although willing to follow her, never supported her choice of treatment and repeatedly expressed his belief my therapy couldnâï¿½ï¿½t work. Such comments can, we have found, influence a patientâï¿½ï¿½s determination to stay with the treatment.
Also, though I did make some adjustments to her program, today I would have pushed the dose of enzymes far more aggressively than I did in 1994. Often, such a change turns the situation around.
In any event, EZ continued on her program until April 1994 when she decided to stop all therapy, nearly five years after she had started with me. She wrote me a gracious note, thanking me for the years of generally healthy good life she had never expected, based on the terminal prognosis given her in 1989. I didnâï¿½ï¿½t hear from her again, until learning of her death more than two years later in August 1996 âï¿½ï¿½ some seven plus years after she had first consulted me in June of 1989.
Eichbaum et al describe a median survival, regardless of the conventional treatment given, of 14 months for women with evidence of metastatic breast cancer into the liver, despite aggressive conventional treatment. (5) In this case, EZ had documented bone metastases as well as multiple liver lesions. Certainly, with her stage IV condition, the evidence of progressive disease despite aggressive chemotherapy, at the time she began our nutritional therapy EZ faced a lifespan that would normally be measured in months. Her seven plus years survival, her generally excellent health during much of that time, and the documented regression of liver and bone lesions over a four year period while pursuing only my regimen represents a most unusual course for a most unusual patient.
Patient GR: A 7-Year Survivor
Patient GR received radiation to the chest as a teenager for treatment of keloids but otherwise had been in good health when in late 1986 she developed a left breast mass. After a biopsy confirmed carcinoma, in January 1987 she underwent a modified radical mastectomy for what proved to be adenocarcinoma, estrogen receptor positive, with metastatic disease in 8 of 23 nodes âï¿½ï¿½ a very poor prognostic indicator. However, chest X-ray, bone scan and abdominal ultrasound showed no evidence of metastatic disease. Postoperatively, GR completed a six-month course of adjuvant chemotherapy with CMF, followed by tamoxifen.
GR did well until late 1990 when she developed pleuritic chest pain which her local doctor treated with antibiotics. She improved somewhat, but then her symptoms worsened in the spring of 1991. After a chest x-ray in April 1991 revealed a left pleural effusion, she underwent thoracentesis, with cytology positive for the presence of malignant cells. A bone scan was negative. Tamoxifen was discontinued in favor of Megace, a synthetic progesterone analog used to treat breast cancer, but her respiratory symptoms only worsened. A repeat chest x-ray in May 1991 demonstrated a persistent pleural effusion, as a note from her oncologist confirms:
Chest x-ray today reveals significant amount of fluid, certainly reaccumulation since her post-tap film...The patient will stay on Megace 80 mgs b.i.dâï¿½¦..She was encouraged not to take unapproved medications for her cancer.
During a follow-up visit in July 1991, her situation seemed to be worsening:
The patient has a significant amount of fluid which would make be (sic) think that the Megace is not working particularly wellâï¿½¦
A chest x-ray in August 1991 showed some slight improvement, described as âï¿½ï¿½Moderately large left pleural effusion, smaller than on the previous examination.âï¿½ï¿½ Since hormonal therapy had failed to control her disease, her doctors suggested aggressive chemotherapy, which GR refused.
GR began investigating alternatives, learned of my work and first came to my office in September 1991. At that time, she continued on Megace, and reported severe shortness of breath as well as a persistent cough. After returning home, she discontinued the drug, began her nutritional protocol and within weeks noted a significant improvement in her breathing and overall well being. She thereafter followed her program faithfully, and when I saw her in my office for a follow-up visit in April 1993, she reported feeling âï¿½ï¿½wonderful,âï¿½ï¿½ better than she had in years. Her respiratory symptoms had resolved and her pulmonary examination was normal. A repeat chest x-ray in April 1993 showed no evidence of pleural effusion or mass lesion. The report states:
Lungs are slightly hyperinflated compatible with chronic obstructive pulmonary disease. There has been a right mastectomyâï¿½¦No acute pulmonary infiltratesâï¿½¦
For the first five years on therapy, GR enjoyed excellent health. However, she frequently reported severe personal stress, including a very difficult divorce involving aggressive legal actions. Over the years, she admitted the haggling with lawyers had begun to wear her out. By late 1996, she had developed fatigue, pelvic pain and chronic nausea that impeded her compliance with the regimen. A CT scan in November 1996 revealed bilateral ovarian masses obstructing the ureters, as the radiologist reported: âï¿½ï¿½These are complicated appearing masses and the differential could include tumors, endometrioma or abscesses.âï¿½ï¿½
A chest CT showed no distinct masses, but:
Loculated low density fluid-like collection in the lower left thorax pleural spaceâï¿½¦.This could be consistent either with empyema or possibly an area of previously treated pleural metastatic disease with thickened pleura.
After ureteral stents were placed to decompress the kidneys, a biopsy of an ovarian mass confirmed recurrent, metastatic breast cancer. Though her doctors insisted GR begin chemotherapy at once, she refused, instead choosing to resume, as best as she could, her nutritional program. Within weeks, she began to improve in terms of her energy and well being. Unfortunately, eventually the stents obstructed again, and the nausea, anorexia and fatigue returned. By the spring of 1997 GR could no longer follow the full program and at my suggestion and that of her local doctors restarted tamoxifen.
Subsequently, as she struggled to continue my regimen, she was seen by a nephrologist at the Mayo Clinic in Arizona, but despite repeated stent changes, her kidney function never returned to normal. Nonetheless, to her doctorsâï¿½ï¿½ surprise, she survived another year, ultimately dying in April 1998, nearly seven years after she had first consulted me.
Though this patient did ultimately succumb, itâï¿½ï¿½s important to emphasize that breast cancer recurring after aggressive chemotherapy and hormonal blockade, particularly when invading an organ system such as the lung, usually kills within months. In this patientâï¿½ï¿½s case, after developing severe pleural effusions in the spring of 1991, she responded only slightly to Megace. However, while being treated solely with our therapy, she had a quick clinical response with resolution of effusions as documented by x-ray studies in April 1993. Her seven years of life after her recurrence, and her excellent health until the last year, certainly illustrate a remarkable course.
Sometimes itâï¿½ï¿½s productive to look for explanations why one patient survives terrible disease, and another doesnâï¿½ï¿½t. In her case, she herself said repeatedly the terrible stress in her life âï¿½ï¿½was killing me.âï¿½ï¿½ Perhaps ultimately it did. Perhaps her body just wore out, after all she had been through, with the disease and the previous toxic treatment. But her family remains to this day grateful for the unexpected years she had with them.
Patient AR: A 14+ Year Survivor
Patient AR is a 74-year-old woman who had been generally in excellent health when she first detected a left breast nodule in August 1991. She did not immediately seek medical attention, instead deciding to self medicate with a number of nutritional supplements and dietary changes. When the mass did not regress, in March 1992, at the urging of a friend, she underwent mammography, which revealed a suspicious left breast lesion.
In April 1992, AR proceeded with a left modified mastectomy. The pathology report describes two distinct lesions, one 2.0 cm in diameter, the other 1.6 cm, both consistent with infiltrating ductal carcinoma, estrogen receptor positive, progesterone receptor negative. Two of 13 evaluated lymph nodes were infiltrated with invasive carcinoma.
Her surgeon strongly recommended a one-year course of chemotherapy because of the positive lymph nodes, but the patient, already intent on proceeding with an alternative approach, declined further conventional treatment including hormonal blockade as well as chemotherapy. Then, after learning of my work, she was first seen in my office in August 1992.
Since that time, AR has been a dedicated, compliant, and very grateful patient. She still diligently follows her regimen, for which she credits the excellent health she has experienced over the past 14+ years. She remains very active, travels, and enjoys a number of outdoor activities.
Her course was very straightforward: after refusing the recommended chemotherapy and hormonal blockade, she has since followed only my nutritional regimen. Though she had no evidence of distant metastasis when she began with me, multicentric disease coupled with lymph node involvement augered for a poor prognosis. I believe she is an informative case, one of a series of women in our practice diagnosed with node positive disease, who avoided chemotherapy, radiation and hormonal blockade, and the attendant side effects, and experienced long-term disease free survival.
Patient RY: A 7-Year Survivor
Patient RY is a 53-year old woman who in January 1999 consulted her primary care physician because of persistent exhaustion. Blood work studies were unrevealing, but during a follow-up physical exam in April 1999 her physician detected a lump in the left breast. Mammography revealed a worrisome area, confirmed by ultrasound as two distinct suspicious nodules. A biopsy followed, documenting, as the pathology report describes, âï¿½ï¿½At least three of these five biopsy specimens are involved by infiltrating carcinoma of ductal type.âï¿½ï¿½
A surgeon then suggested immediate mastectomy, but RY, with a long interest in alternative healing techniques, decided to delay surgery and instead traveled abroad for a stay at a healing retreat. She admits she hoped that intensive meditation coupled with a wholesome diet might generate a spontaneous remission.
When she returned home she sought a second opinion at a major teaching hospital in the Canadian city in which she lives. After the doctors again discussed surgical options, she agreed to a double lumpectomy in the left breast for excision of the two lesions identified on ultrasound, along with axillary dissection. In late December 1999, she underwent surgery as planned. The pathology report describes a 2.2 cm tumor, high grade III, estrogen receptor positive, with lymphatic vascular invasion. The tumor extended nearly to the surgical margins, and two additional areas distant from the main lesion proved to be cancerous. Cancer had also infiltrated into 13 of 16 lymph nodes, an indication of a dire prognosis.
In mid January, at a follow-up visit, her surgeon urged that because of the lymph node involvement, she consent to a course of aggressive chemotherapy. At that point RY, who had learned of our work, decided to proceed with our therapy. When we met for the first time in mid January, only several weeks after her surgery, she seemed to have weighted the options carefully and said bluntly she would refuse all conventional treatments.
After returning home to Canada, she began my program, which she followed with diligence. In March 2000 she did meet, as had already been planned, with an oncologist, whom she reported “went nuts” when she told him she was refusing chemotherapy. After he calmed down, he admitted that even with aggressive chemotherapy, he could promise perhaps a 5% chance of long term survival due to the extensive lymph node involvement at the time of diagnosis.
In April 2000, after she had been on our therapy for three months, she detected a new nodularity in her upper left breast. An ultrasound revealed:
Two solid nodules are seen in the left upper outer quadrant....I feel they should be viewed with suspicion, as they may represent involved lymph nodes. Sonographically guided biopsy is recommended.
RY chose not to proceed with biopsy, but instead concentrated on her nutritional program. Thereafter, she declined further radiographic testing, stayed faithfully on her nutritional regimen, and today, nearly seven years from our first meeting, enjoys generally excellent health. The left breast nodularity long ago regressed.
The Adjuvant! Online website provides survival statistics for a variety of cancers, broken down by specific stage. I was able, on the site, to find numbers that would apply to someone like RY. In women undergoing surgery for breast cancer who have nine or more positive nodes but no evidence of distant spread, and who receive no adjuvant therapy, only 5.7% will be alive and disease free at ten years. (6) So, the numbers are better than what experts report for those with breast cancer that has invaded distant organs, such as the liver, brains or bones, but they are still not great.
In this case, the nature of the tumor - grade III/III on the Bloom/Richardson scale âï¿½ï¿½ itself portended a potentially poor prognosis, as did the 13 involved nodes. Importantly, during the initial months on therapy, on exam and as confirmed by ultrasound, RY had evidence of recurrent suspicious nodularity which subsequently regressed. In any event, in the seven years that she has been our patient, RY has successfully avoided chemotherapy and any other conventional treatment.
Patient RA: A 4.5-Year Survivor
Patient RA has a family history pertinent for multiple cases of cancer, including breast cancer. She herself had a long history of fibrocystic breast disease, followed closely by her doctors at the major academic center in the city in which she lives. In 1990, she developed a new left breast mass, that was initially not thought to be problematic, based on ambiguous mammography findings. When the mass persisted, in May 1991 she underwent aspiration of the nodule, which yielded cells suspicious for malignancy. Because of the worrisome findings, coupled with her strong family history of breast cancer, RA decided to proceed with prophylactic bilateral mastectomies. So, in May of 1991, she underwent a left modified mastectomy and a right simple mastectomy with lymph nodes left intact.
The right breast appeared to be cancer free, but a 1.2 cm lesion in the left breast proved to contain both infiltrating and lobular carcinoma, and four of 18 axillary nodes were positive, a negative prognostic indicator.
After surgery, an oncologist suggested RA enter a clinical trial comparing standard chemotherapy for node positive breast cancer against a new regimen consisting of Cytoxan, epirubicin and 5-FU, for six full cycles. After RA agreed to participate, she was assigned to the epirubicin arm of the study. She tolerated the protocol poorly, experiencing not only chronic nausea and fatigue but a persistent peripheral neuropathy. Despite the side effects, she completed the regimen on schedule in December 1991.
Thereafter, RA reports her health deteriorated significantly. She describes an unending series of various infections, including chronic cystitis, sinusitis and upper respiratory infections. Then in July of 2001, nearly ten years after she had completed chemotherapy, her oncologist noted enlarged bilateral axillary lymph nodes. Her physicians, for reasons I donâï¿½ï¿½t understand, initially suggested neither biopsy nor treatment. When the lymph nodes did not regress, in December 2001 her primary care physician ordered ultrasound studies of axillary regions, which showed eight enlarged nodes on the right, two on the left.
In January 2002 a biopsy of a right axillary node confirmed metastatic carcinoma consistent with a breast primary, estrogen and progesterone receptor positive. Follow up studies, including a liver-spleen scan, chest X-ray and bone scan were all clear.
RA then consulted her former surgeon, who suggested that both axillae be âï¿½ï¿½cleaned out,âï¿½ï¿½ a procedure she declined. When in February 2002 her oncologist then recommended not chemotherapy but a trial on tamoxifen, she agreed to the plan. But she also began looking into alternative approaches and learned of our work.
When I first saw RA in May of 2002, she was still taking tamoxifen, but anxious to quit because of ongoing severe side effects. On physical exam, she had evidence of enlarged bilateral axillary nodes. She thereafter began her nutritional regimen, discontinued the tamoxifen, and noted gradual improvement in her overall health. A variety of chronic symptoms and problems, including fatigue, neck pain, malaise and severe allergies have largely resolved. Today, more than four and a half years since starting her nutritional regimen, she remains a determinedly compliant patient, and is in good health with no evidence of enlarged nodes anywhere, including in the axillae. Since stopping tamoxifen, she has received no conventional therapy.
Her case is unusual for a number of reasons. Her bilateral axillary disease developing after aggressive chemotherapy predicted a dismal prognosis. On her nutritional program, the tumors regressed and remain so today.
Patient ZA: A Four Plus Year Survivor
Patient ZA had a family history pertinent for two first-degree relatives with breast cancer, and a third who died of stomach cancer. She had herself been in good health, with a distant history of localized melanoma, when in early 1989 she first noticed a painful lump in her right breast. Mammography was unrevealing, but after a biopsy in May 1989 confirmed carcinoma of the right breast, she underwent right modified mastectomy. The tumor consisted of infiltrating ductal carcinoma and in situ carcinoma, estrogen receptor and progesterone receptor negative, but all lymph nodes were cancer free. After a postoperative bone scan and CT scan of her abdomen were both clear, she then began a nine-month course of chemotherapy with methotrexate and 5-FU
ZA did well until March 1993, when she noticed a nodule on the right upper chest wall that both her oncologist and surgeon thought was insignificant. Her primary care physician, less sanguine about the situation, referred ZA to another surgeon who in July 1993 biopsied the lesion, which proved to be recurrent moderately differentiated adenocarcinoma. A bone scan showed suspicious activity in the right third rib, but x-ray studies did not confirm the finding. A CT scan of the chest in late July 1993 revealed normal lungs but âï¿½ï¿½Multiple tiny areas of low attenuation in the liverâï¿½¦.although some of which are intrahepatic vasculature, others are felt to be due to metastasis.âï¿½ï¿½
A CT scan of the liver in August documented âï¿½ï¿½Occasional areas of low attenuation throughout the liverâï¿½¦ these most likely represent an early metastatic process.âï¿½ï¿½
In August 1993, at the urging of her oncologist, ZA began a course of radiation to the chest wall for âï¿½ï¿½local control,âï¿½ï¿½ an approach that makes little sense since the disease had already spread into the liver and possibly into the bones. Unfortunately, she suffered such significant side effects from radiation, including severe burns, that the treatment had to be prematurely discontinued. Her oncologist then insisted she resume aggressive chemotherapy, but the patient, realizing her disease was now incurable by conventional standards, refused the drug treatment and began investigating alternatives. After learning of my work, she decided to proceed with our treatment and first consulted with me in October 1993. At the time, she had recovered from her radiation experience, and seemed to be feeling quite well despite her liver disease.
Thereafter, for a time she was an extremely dedicated and compliant patient, aware her life was on the line, and initially she did quite well. A CT scan in February 1994, after she had followed her nutritional regimen for only five months, showed âï¿½ï¿½Overall improvement in the metastatic process in the liver with some residual areas of low attenuation compatible with a metastasis.âï¿½ï¿½ The patientâï¿½ï¿½s oncologist, who had so firmly insisted ZA resume chemotherapy after the positive CT scan findings in August, now claimed she couldnâï¿½ï¿½t possibly have had cancer in the liver, since it was inconceivable my âï¿½ï¿½bizarreâï¿½ï¿½ treatment could have provided any benefit. ZA at that point got herself another physician to monitor her local care.
When I saw her again in New York in June 1994, eight months after her first visit, she was feeling remarkably well, with excellent energy and well being. However, I saw the first signs of trouble when she admitted she had gotten careless with the critically important supplements. After I lectured her at length about the need in her case for not good, but perfect compliance, she returned home with renewed dedication.
A bone scan in October 1994 was interpreted as âï¿½ï¿½Essentially unremarkable,âï¿½ï¿½ indicating the previously noted rib lesion had resolved. I next saw her in the office in July 1995, at which time she reported no problems and said she felt âï¿½ï¿½wonderful.âï¿½ï¿½
She had no further testing until October 1995, when she had completed two full years on her nutritional protocol. A chest x-ray was normal, and a CT scan of the abdomen with and without contrast showed total resolution of the lesions in her liver. The report reads âï¿½ï¿½Normal CT of abdomen without and with I.V. contrast.âï¿½ï¿½ Her diffuse liver metastases were gone.
During the first several years of therapy, we require that all our out of town patients return to New York every six months, for a lengthy in-office reevaluation. I find I can learn more about whatâï¿½ï¿½s going on with a patient after ten minutes face to face, then in a two-hour phone consultation, particularly regarding such life and death issues as compliance. In ZAâï¿½ï¿½s case, though she was next due for a return visit in the spring of 1996, in February she called saying she could not come to New York because of financial considerations. Unfortunately, insurance companies pay only for âï¿½ï¿½standard of careâï¿½ï¿½ treatments, and in this case, ZAâï¿½ï¿½s company paid nothing for her nutritional regimen âï¿½ï¿½ despite her several appeals based on the documented response to our regimen. Already, by 1996, her financial constraints âï¿½ï¿½ tragically âï¿½ï¿½ raised red flags. When strapped, patients tend to cut back on the supplements âï¿½ï¿½ an invitation to disaster with advanced deadly cancer.
When we spoke by phone in early March 1996, she admitted she had again been feeling so well she had become sloppy with all aspects of the therapy. She had resumed eating sweets, forbidden food on the therapy, and was consuming far more animal protein than we had allowed on her particular diet. She had cut down the frequency of the coffee enemas, which we find essential for success, and she had been missing doses of supplements, including the enzymes âï¿½ï¿½ the main anti-cancer element of the therapy. I lectured at length about the need for vigilant compliance and she promised she would do better.
In early July 1996 a bone scan revealed a new lesion in the right seventh rib, consistent with a metastasis. Shortly after, she returned to New York for a visit in the summer of 1996, nearly three years after she had begun my program. Although she reported she felt âï¿½ï¿½great,âï¿½ï¿½ her compliance was far off track and I could see that she had been lulled into complacency. To make matters worse, not only was she inadequately compliant with my regimen, but a local âï¿½ï¿½holisticâï¿½ï¿½ practitioner had suggested, without consulting me, that she begin taking a variety of supplements, including the hormone DHEA, which I never would have prescribed for someone with her history.
After returning home, in September she developed open sores on her chest wall, I believe directly as a result of damage from the earlier radiation therapy. I urged her to be fully compliant, stick with my protocol and throw away the supplements from her local doctor. For a time, she did seem to be more determined, and by mid January, the residual chest lesion had regressed somewhat, to the size of a small pea. However, in February, biopsies of a chest wall and right neck nodule confirmed adenocarcinoma.
I was due to see her for a return office visit in February 1997, but she again said she couldnâï¿½ï¿½t afford to come to New York. During early 1997, we talked frequently by phone, and though her energy was generally quite good, she developed a chronic cough. A bone scan in June showed new areas of involvement, and by July 1997, she had been diagnosed with pleural effusions. These were drained with some symptomatic improvement, but the fluid tested positive for malignant cells.
I never saw ZA in my office after the August 1996 visit, though we kept in touch at least on a weekly basis throughout much of 1997. As her situation deteriorated, she required multiple thoracenteses for reaccumulating effusions. By mid fall, she had great difficulty sticking to her nutritional program and she finally died in late December of 1997 âï¿½ï¿½ four years, two months after she had first come to my office, and nearly four and a half years since her diagnosis of recurrent disease in the chest and liver.
Although she ultimately died, ZA far outlived the usual prognosis for breast cancer recurring in multiple sites (in her case, the liver and bone) after a course of aggressive chemotherapy. After two years of good compliance on treatment, CT and bone scans confirmed resolution of her previously widespread disease. Thereafter, for any number of reasons âï¿½ï¿½ finances, the influence of local doctors, her overconfidence âï¿½ï¿½ her adherence to the regimen fell off considerably. Nonetheless, this patientâï¿½ï¿½s significantly improved clinical status on therapy, the radiographic findings of tumor regression in the liver, and the long term survival indicate a significant response to treatment.
Eichbaum et al studied a group of 350 women with breast cancer that had metastasized to the liver. (4) The authors describe a median survival, regardless of the conventional treatment given, of 14 months.
Patient FQ: A 9-Year Survivor
Patient FQ is a 57-year-old women who had been in generally excellent health when in October 1997, her gynecologist detected a large right breast mass, subsequently described on mammography as a suspicious lesion approximately 5 X 4 cms in diameter. The patient was referred to a surgeon who noted dimpling in the mass, a sign of aggressive disease, and suggested mastectomy followed by radiation and chemotherapy as his note reports:
I discussed the treatment options with the patient from lumpectomy and axillary node sampling with postoperative radiation to modified radical mastectomy. We also discussed the probable need for adjunctive therapy with radiation and/or chemotherapy. I think with the size of the patientâï¿½ï¿½s lesion and its proximity to the nipple that a modified radical mastectomy will in all probability be the best treatment for her lesion.
The patient, who was already quite familiar with my work, initially wanted to refuse all conventional approaches and begin my treatment. When she called our office wishing to make an appointment, we insisted she proceed at least with surgery. So, in December 1997 she underwent a lumpectomy and axillary node sampling. The pathology report describes a âï¿½ï¿½4.09 x 3.0 x 3.0 tumor mass,âï¿½ï¿½ consistent with moderately differentiated infiltrating tubulolobular carcinoma. The margins appeared tumor free, but cancer had invaded two of nine sampled nodes.
Other than a clear preoperative chest x-ray, no other radiographic studies were pursued. Her surgeon however, insisted she consult with an oncologist and proceed with both radiation to the chest and chemotherapy. His notes state:
I have reinforced the need for the patient to see an oncologist as soon as possible and proceed on with chemotherapy and radiation therapy as appropriate following her oncologic evaluation.
FQ, having already decided to proceed only with my treatment, never did meet with the local oncologist. When we first met in my office in January 1998, she insisted she would not submit to chemotherapy. Subsequently, she proved to be a very determined and compliant patient and today, nine years later she follows a modified nutritional protocol, enjoys excellent health and leads a full and productive life. In all this time, she has remained cancer free.
I thought I would include this case for several reasons. Though she had no evidence of active disease at the time she started with me, her large tumor and involvement in two lymph nodes portends for a poor prognosis long term. The standard treatment for such node positive disease has been for more than twenty years, aggressive âï¿½ï¿½adjuvant chemotherapyâï¿½ï¿½ after surgery. Such treatment, as the studies going back 30 years show, offers an improvement in disease free survival compared to surgery of some 10-15% âï¿½ï¿½ not an extraordinary advantage, but a mathematically significant one nonetheless. Today, oncologists invariably add intensive radiation to the chest wall as well, and if the tumor is estrogen receptor positive, long term hormonal blockade.
For periodic updates about our work and our website, please subscribe to our mailing list.
1. Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo, DL, Jameson JL. Harrisonâï¿½ï¿½s Principles of Internal Medicine, 16th Edition. New York: McGraw-Hill; 2005:516.
2. DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles and practice of oncology, 6th Edition. Philadelphia: Lippincott Williams & Wilkins; 2001:1700-1.
3. Elder EE, Kennedy CW, Gluch L, Carmalt HL, Janu NC, et al. Patterns of breast cancer relapse. Eur J Surg Oncol. 2006;32(9):922-7. [Abstract]
4. Lentzsch S, Reichardt P, Weber F, Budach V, Dorken B. Brain metastases in breast cancer: prognostic factors and management. Eur J Cancer. 1999;35:580-5. [Abstract]
5. Eichbaum MH, Kaltwasser M, Bruckner T, de Rossi TM, Schneeweiss A, Sohn C. Prognostic factors for patients with liver metastases from breast cancer. Breast Cancer Res Treat. 2006;96:53-62. [Abstract]
6. Adjuvant! for Breast Cancer (Version 8.0) at www.adjuvantonline.com. Accessed on October 25, 2006.