Ayurvedic and Naturopathic Approaches to Stage 4 Squamous Cell Carcinoma: �A Case Study

With Virender Sodhi, MD (Ayurveda), ND

Introduction to Squamous Cell Carcinoma

• “Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer and the second most common form of keratinocyte carcinoma after basil cell carcinoma (BCC)�Like BCC, cSCC is increasing in incidence throughout the world. In the United States, lifetime risk for development of cSCC is estimated at 9% to 14% for men and 4% to 9% for women” – Journal of American Academy of Dermatology¹
• Immuno-suppression is now being considered another major contributor to increased incidence.²
• The prognosis of different histological types of is significantly different. The 5-year survival rate of Keratinizing SCC is >80%, while the 5-year survival rate of hypokeratinizing and nonkeratinizing SCC is >50%³

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Refresher on Lesion Parameters¹

• Skin lesions that have the following characteristics are considered higher risk by the National Comprehensive Cancer Network:
• >20mm on the trunk and extremities (excluding hands and feet)
• >10mm on the cheeks, forehead, scalp, neck, and pretibial.
• Any size lesion on central face, eyelids, eyebrows, periorbital skin, nose lips, chin, mandible preauricular and postauricular skin, temple, ear, genitalia, hands and feet.
• Poorly defined boarders
• Lesions that reoccur post excision
• Neurologic symptoms related to the lesion
• Black or red colors are considered higher risk than brown or tan.

JAAD Guidelines of Care for cSCC: �Surgical Treatments¹

• A treatment plan that considers recurrence rate, preservation of function, patient expectations, and potential adverse effects is recommended.
• Curettage and electrodessication may be considered for low-risk, primary cSCC in non–terminal hair–bearing locations.
• For low-risk primary cSCC, standard excision with a 4- to 6-mm margin to a depth of the mid-subcutaneous adipose tissue with histologic margin assessment is recommended.
• Standard excision may be considered for select high-risk tumors. However, strong caution is advised when selecting a treatment modality for high-risk tumors without a complete margin assessment.
• Mohs micrographic surgery is recommended for high-risk cSCC.

JAAD Guidelines of Care for cSCC: �Non-Surgical Treatments¹

• Radiation therapy (eg, superficial radiation therapy, brachytherapy, external electron beam therapy, and other traditional radiotherapy forms) can be considered when tumors are low risk, with the understanding that the cure rate may be lower.
• Cryosurgery may be considered for low-risk cSCC when more effective therapies are contraindicated or impractical.
• Topical therapies (imiquimod or 5-FU) and photodynamic therapy are not recommended for the treatment of cSCC on the basis of available data.
• There is insufficient evidence available to make a recommendation on the use laser therapies or electronic surface brachytherapy in the treatment of cSCC per the Journal of the American Academy of Dermatology

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Case Presentation

• 51-year-old Indian male, former IT Executive. Now reliant on a feeding tube.
• First diagnosed with keratinizing type Squamous cell carcinoma in November 2021 arising from the bottom of the mouth and invading into the jaw.
• Treated previously in India with chemotherapy x 5 treatments before going to USA for surgery and plastic surgery.
• His condition was managed for 6 months before it came back.
• The cancer spread rapidly throughout the head and neck, creating a chronic malignant wound, disfiguring his face and causing multiple abscesses in the face and jaw.
• The family had a history of SCC
• The patient was then treated with Cetuximab
• The patient was referred to me as a last resort once he was told he had two weeks to live.
• Palliative intent of treatment first discussed 2/9/23

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Medications

• Acetaminophen 650mg
• Cetirizine 10mg
• Cetuximab 500mg 250mL IVPB x 3 infusions
• Dexamethasone 12mg injections
• Famotidine injection 20mg injections.
• Oxycodone 5mg q4h
• Polyethylene glycol
• Tranexamic acid 1000mg/mL solution applied topically to stop bleeding
• Metronidazole .75% topical gel to apply BID to help with the odor of his wounds.
• Clindamycin 1% gel for cetuximab related rash.

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Disclaimer

Graphic Image Warning

Initial photo

Initial Photo upon entering my care

The Mind as the Source of Disease

• In Ayurveda there is a saying, “All disease starts in the mind.”
• In my practice, I see disease as very directly tied to the regular emotional state of the patient.
• In this patient when I met him, he was a very frustrated person, understandably, and his family remarked he had big shifts in his personality.
• Part of our work together relied on helping him calm himself, meditate, and work through our emotions, and I believe that it cannot be overstated that this is an essential part of our medicine.
• We need to empty the mind like we empty the body:
• Make it a daily habit not unlike a bowel movement
• The more you remove, the more ready you are for learning

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The Importance of Hope

• Our rapport with our patients is one of our most vital and precious tools, and often can be what sets us apart from others in the medical field.
• Even when proven medicines are prescribed to the patient, if the patient does not have the faith by himself and with the physician the treatment may not be successful. 

In Ayurveda, this is a cornerstone of the medicine:

• Acharya Sushruta, largely considered one of the fathers of ancient surgery, explains in the seminal work, the Sushruta Samhita¹, the way the mind and spirit interplay to help or harm cure. He states:
• The cure of the disease mainly dependent upon your mind;
• The cure will be faster if the individual is stress free and cool and calm.
• If the individual has confidence and hope (followed with concentration), it eases the process of healing or pacifying the ill causing a health condition.
• If the patient perceives the healer in a bad light, the patient may never get better, even when appropriate methods are used.
• This is why extreme caution and discernment should be used when telling a patient how much time they have left, as in the case of this patient who was “given two weeks to live”

My approach

• First and foremost, I saw this person with the utmost compassion.
• Dietary changes
• Vegetarian Ketogenic Diet
• Lifestyle changes
• Yoga, Meditation, Forest Bathing, Pranayama
• Herbs and Supplements
• Curcumin, Vitamin D, Guggal, Tinospora cordifolia, Turkey Tail, Neem, Probiotics
• IV treatments
• Ascorbic Acid, ALA, Curcumin and Quercetin, Mistletoe

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Treatment Plan: Diet

• Dairy A2 cow's milk, yogurt, butter, cream.
• May have nut milks �
• Cut down carbs , use as little as possible. �
• Start making smoothies of green leafy vegetable, it should be very runny and filter it.
• Normal saline was used to clean the feeding tube.�
• Start slow and then increase the amount of vegetables in diet. Start with one cup per day and then see how things shape from there.
• Can add 1 teaspoon ginger powder. �
• Foods
• Beans/legumes were essential to quelling inflammation.
• For fruits only berries, in the form of smoothies.
• Make nuts and seeds smoothies. It should be unsalted and unroasted. Variety is important.
• Avoid peanuts - common allergen and mold contamination�
• Vegetable oils: 1 tablespoons of healthy oil poured on top of food. Do not fry with it.
• Good oils: olive, coconut, sesame, avocado, mustard, walnut, ghee.
• Bad oils: soybean, corn, cottonseed, canola, vegetable shortening.

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Keto and Cancer: �A Research update

• Keto continues to find favor in cancer research.
• Randomized trials are becoming more commonplace, but are still few and far between.
• One study looking at quality of life in stage 2 and stage 3 cancer patients found improvements in QoL and mental health compared to standardized traditional diet.¹
• Estrogen sensitive cancers appear to be the most commonly studied in conjunction with the ketogenetic diet.
• One proposed mechanism in a study of breast cancer patients found the keto diet might exert beneficial effects through decreasing TNF-α and insulin and increasing IL-10. Cancer stages decreased significantly in patients with locally advanced disease in the KD group after 12 weeks.²
• Multiple studies have demonstrated safety and tolerability. ^3,4

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Treatment Plan:�Yoga

• Instrumental to keeping the channels of the body (Abhishyandi) clear thus preventing build up of toxins in the body in Ayurveda.
• Often practiced with breathing exercises.
• Research supports the incorporation of breathing exercises such as alternate nostril breathing for supporting better stress response.

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��The Research: Yoga

• Yoga postures were originally done barefoot on the Earth.
• One study found that benefits of yoga on anxiety, depression, and fatigue lasted 6 months after discontinuing yoga practice.¹

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• A study of 400 cancer survivors showed improvements in cancer-related fatigue. ²
• Another study demonstrated a decrease in pro-inflammatory cytokines IL-6 and IL-1β after 12 weeks of weekly yoga. ³
• It was noted that TNF-α production did not decrease.
• Studies show that anger increases homocysteine levels and increases risk recurrent cardiac events.⁴
• Remember the Ayurvedic postulate: The mind and spirit initiate nearly all disease.
• And yet, one study found Yoga decreases homocysteine levels.⁵
• In research, the “dose” of Yoga is not standardized, but studies average 60 minutes, once a week, for between 8-12 weeks or 30 minutes, twice a week, for 8-12 weeks.

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Pranayama / Breathing Practices

When the breath wanders the mind also is unsteady. �But when the breath is calmed the mind too will be still, and the yogi achieves long life. �Therefore, one should learn to control the breath.� ~Svatmarama, Hatha Yoga Pradipika�

• Pranayama has been researched and found to improve symptoms of depression, anxiety, fatigue, sleeplessness, and overall quality of life in a dose-dependent manner (the more regular it is done, the more effect you get).¹
• Four necessary factors:
• A stepwise reduction in breath frequency.
• Utilizing a 1:2 ratio between the duration of inspiration and expiration (4 seconds in, 8 seconds out).
• A breath suspension at the end of inspiration that is twice as long as the expiration.
• Mental concentration on breathing.
• This patient was recommended So-Hum breathing:
• 1. Inhale through your nose, filling your lungs to full capacity using your belly.
• 2. Hold the breath as long as you can until you feel uneasy, then slowly exhale through your mouth.
• 3. Repeat this exercise 10 min, twice a day.
• This particular technique was chosen as it has an emphasis on relaxation and calming the mind.
• Studies suggest Pranayama may also stimulate the vagus nerve and promote parasympathetic tone. There are also reductions in cortisol that have been seen.²
• This is a free and effective way to support your patients, especially those who desire more structure than simply sitting quietly for meditation. �

�Forest Bathing

• Spending time in nature is essential for human health.
• Lasting reductions in blood pressure, inflammatory cytokines, cortisol, and IL-5 have been observed in humans.^1,2
• Controls included walking through cities did not demonstrate these effect
• Increase natural killer (NK) activity, the number of NK cells, and the intracellular levels of anti-cancer proteins have also been observed.³
• Grounding aka Earthing studies have shown decrease in anxiety and depression that lasted over a month after the intervention was ceased.⁴
• Ayurveda teaches “walk barefoot” as part of the foundations of health.
• Moreover, this patient was ambulatory, and I felt it was essential for him to clear his mind, reconnect with the world around him.

Treatment Plan: Supplements and Herbs

• Curcumin one teaspoon twice a day
• (1.75g per teaspoon)
• Vit D 10,000 IU per day
• Guggul 300 mg cap twice a day
• Tinospora cordifolia 100mg twice a day
• Turkey Tail 2 cap twice a day
• Neem leaf internally
• Probiotic twice a day

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Curcumin: �The Research

• Several preliminary studies demonstrate curcumin has effects on oral SCC cell lines even in low concentrations.¹
• There are not human trials on SCC as of now; however, there are several studies of other cancers including:
• Curcumin can be safely combined with FOLFOX chemotherapy in colorectal cancer.²
• A 0.1% curcumin mouthwash delays the onset of radiation induced oral mucositis. Another meta-analysis found that both curcumin and turmeric are safe and well tolerated and provide benefit.³
• Orally 1,500- 2,000mg per day was also found to be safe.⁴

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Curcumin Vs Whole Turmeric

• There is a current discussion around the use of curcumin versus whole plant turmeric for acquiring the many benefits which are related to both curcumin and turmeric.
• Curcumin has been important in beginning the conversation as it can be isolated into either a single form, or used as the mixture of curcuminoids it naturally occurs as. This follows traditional drug discovery research pathways.
• That said, traditional wisdom will always favor whole plant and research is beginning to understand this.
• Research suggests that there is slightly better evidence to support Turmeric for cognitive concerns, and as a probiotic whereas curcumin appears to have better evidence as an anti-inflammatory. Though this isn’t conclusive.
• My clinical opinion favors whole turmeric in general for cancer care.

Guggul�Commiphora wightii

• Guggulsterones have effects on NFkB and acts as an anti-inflammatory.¹ �
• It has also been studied and shown to be an anodyne which I find it very useful.²

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• In Ayurveda it’s favored for ear, nose and throat conditions
• Which is why Boswellia wasn’t used, as it has more of a respiratory affinity in Ayurveda. �
• It is additionally well understood to effect blood lipids. ³�
• Herb/Drug Considerations:
• Only in-vivo and in-vitro studies have demonstrated CYP3A4 antagonism with isolated guggulsterones’s E and Z. ⁴
• I have not experienced any issues employing guggal. �

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Guduchi�Tinospora cordifolia

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• It has been studied for arresting specifically in human oral squamous cell carcinoma cells.¹
• It is still in its infancy in research, but preliminary research is promising. It has been found to have effects on colon, SCC, and cervical cancers.²
• It is also used in Ayurveda to remove “Ama” or essentially all toxins of the body.
• It also is well studied for its antioxidant and liver protective effects.
• It has been studied in chronic alcohol users with significant results, particularly in lipids and hormone levels. ³
• An herb that truly deserves more dedicated research to elucidate its many benefits.
• Herb/Drug Considerations:
• General recognized as safe and has been studied in-vitro and not found to be a major interactive agent with CYP450 isozymes.⁴

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Neem Leaf�Azadirachta indica

• Neem demonstrates oncostatic potential via several mechanism including:¹
• Suppression of the NF-κβ pathway
• Increased expression of tumor suppressor (such as p53 and pTEN)
• Decreased expression of oncogenes (such as c-Myc)
• Increased apoptosis in cancerous cells
• Human trials of neem are largely focused on immune support and viral prophylaxis.²
• Another study has shown promise in attenuating insulin resistance and improving glycemic control.³
• This is another reason it was selected for this patient as we also dietarily restricted sugar.
• Herb/Drug Considerations:
• Use with caution in insulin-dependent diabetic patients or those on antihyperglycemic drugs.

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Treatment Plan: Topical Approaches

• Neem oil and Kalanji oil (black seed oil) to apply topically to the wound.
• Bi-Weekly cold laser therapy with far infrared used over wound.

Neem Oil

• We have already discussed the benefits of neem leaf internally.
• The oil is also extremely useful as a topical antiseptic.
• It has been studied in acute skin toxicity from combined radiotherapy and chemotherapy in head and neck cancer patients.¹
• It synergizes well with other herbal oils such as Calendula and St. John’s wort.
• Used extensively in Ayurveda for diabetic foot ulcers.
• Useful in particular for nerve pain as a topical approach combined with SJW oil.

Black Seed Oil

• Deeply nourishing to the skin and studied in breast cancer patients to decrease the severity of acute radiation dermatitis.¹
• Powerfully antibacterial and often used in cosmetics for this purpose.²
• Also studied internally for children with ALL to prevent methotrexate hepatoxicity (80mg/kg/day)³ and doxorubicin-induced cardiac toxicity (also 80mg/kg/dose divided into 3 parts starting at the same moment of starting doxorubicin infusion therapy).⁴
• It as also has been studied in relieving nasal dryness, burning, obstruction, itching and crusting in the elderly, fun fact!⁵
• This also reminds me that Ayurvedic medicine recommends oiling the orifices as a part of everyday health.

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Laser Therapy

• Performed at the same time as IV therapy.
• Red/blue/green/UV/yellow all used together.
• 10 minutes of each color.
• Eventually attached all the lights to a single plastic ring and held up with a microphone stand, able to be a few centimeters from the face.
• Meta-Analysis of 12 studies concluded that laser therapy has a significant prophylactic effects on oral mucositis secondary to oncotherapy.¹
• An important study looked at cost-effectiveness of low-level laser therapy in head and neck cancer patients receiving radiation and found that morbidity was lower in the laser group and was more cost effective than placebo up to a threshold of at least $5,000 per mucositis case prevented.²
• An important consideration in the discussion of complementary treatments and their cost/benefit analysis.
• It has also been studied as effective for cancer related lymphedema.³

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My homemade laser combination

Treatment Plan: IV Protocol

1. 50g Ascorbic Acid + 10ml MgCl in 500 NaCl 0.9% -- twice weekly (this patient was not afflicted with genetic 6GDP deficiency)
1. I would use <6g with 6GDP deficiency.¹�
2. Alpha Lipoic Acid 25mg/ml 10ml in 250 NaCl 0.9% -- twice weekly covered with UV protective lining and tubing.�
3. Curcumin (5ml) and Quercetin (2ml) in 250 NaCl 0.9% -- twice weekly. �
4. Mistletoe extract: 0.8-1ml subQ on alternating forearms prn.

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Results

•  He was only given weeks to live but he is still alive months after we started care.
• His quality of life improved: he can work (very important for his spiritual and mental health)
• He did have pain, but he was able to work 5 days a week.
• He can walk for longer distances.
• He cracked jokes again after months of anger and frustration.
• The fatigue was major issue for him, and he reports much less fatigue.

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Graphic Image Warning

Comparing from start to present day.

Results after 3 months of care:

Initial photo:

Current photo:

Follow up

• Patient went for plastic surgery.
• It ended up harming him because his body rejected the grafts, and we are still working on the pain and these issues.
• He was hospitalized for 5 weeks. They did not adhere to his diet nor give him access to his supplements. Resulting in increased pain.
• He is home now and currently restarting his health regimen.

Future Plan

• Potentially Datar genetic testing to further understand treatment options.
• Continue diet, herbal, and IV treatments.
• Continue lifestyle changes.
• Focus on neuralgia pains with laser and topical neem and St. John’s wort applications.

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Conclusion

• This patient was sent to me with an alleged “two weeks to live” and his family was desperate.
• Using everything in our naturopathic toolkit has not only extended his life but has greatly improved his health and wellbeing.
• This case study stands as a testament of the value of our medicine even in the most dire of circumstances.

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Thank you!

Questions?