Calendula (Calendula officinalis). Photo Courtesy of NewMark.

About 200,00 women in the U.S. are diagnosed with breast cancer each year, and a large portion of them receive conservative surgery and radiotherapy. In approximately 80%, irradiation will induce mild to severe dermatitis. In some cases, the pain and skin damage is severe enough to interrupt treatment.

There are many topical treatments purported to prevent or ameliorate radiation dermatitis, including corticosteroids, non-steroid creams, herbal formulations, vitamin E ointments and aloe vera.

Until recently, there were no large randomized studies showing the efficacy of any topical non-steroid in the prevention of radiation-induced dermatitis in breast cancer patients, which is why I was pleased to learn of a new study documenting the effectiveness and even superiority of calendula ointment in preventing acute dermatitis during postoperative breast irradiation. Oils and extracts of calendula (Calendula officinalis) have a long history of use as topical treatments for burns, dermatitis, and other skin conditions.

The study compared a calendula ointment (Boiron Ltd.) with trolamine, a topical nonsteroidal, for the prevention of radiation-induced dermatitis in 254 women with breast cancer. Trolamine is an oil-in-water emulsion that can enhance the healing of the skin by modifying immunomodulators and recruiting macrophages. The secondary objectives were to assess pain, interruption of radiotherapy, patient satisfaction, and the quantity of ointment used.

All patients had undergone surgery for breast cancer and were to receive postoperative radiation therapy. Half were assigned to the trolamine group and half to the calendula group. They applied the agents to the irradiated fields after each session, twice daily or more, depending on the occurrence of dermatitis and pain, until completion of their radiotherapy.

The incidence of acute skin toxicity of grade 2–3 was 41% in the group given calendula and 63% in the trolamine group. Nine patients given calendula and 20 patients given trolamine presented with a grade-3 toxicity. No patient in either group had a grade-4 toxicity. The benefits were the most significant at the submammary fold, armpit, and tangential area, as well as at anatomic sites with very thin skin. Only one patient receiving calendula had to interrupt radiotherapy, but this was unrelated to skin toxicity. In contrast, 15 patients using trolamine had treatment interruptions, 12 due to skin toxicity.

The calendula ointment was statistically significantly superior to trolamine for prevention of skin toxicity of grade 2 or higher, and for other end points including allergy, interruption of treatment, patient satisfaction, pain relief and dermatitis. Patients were also able to use a lesser quantity of calendula than trolamine. The only inferior aspect of calendula according to patients was that it was more difficult to apply (Pommier P, Gomez F, Sunyach M, et al. J of Clinical Oncology. 2004; 22(8):1447–53).

In a previous randomized, open, parallel study, calendula was shown to be effective for the local treatment of second and third degree burns. The clinical relevance of the current findings may easily extend to other patients receiving external beam radiotherapy.

Caloric Restriction Reduces Risk of Invasive Breast Cancer

A retrospective cohort study showing marked reductions in breast cancer among women who had been anorexic as teenagers underscores the profound influence of dietary factors, especially early in life, on later cancer risk.

There is a strong body of animal data indicating that calorie restriction early in life will both extend lifespan and reduce the incidence of a wide range of cancers, including malignant mammary tumors. In humans, there is considerable epidemiologic evidence linking obesity with breast cancer, but until recently, it was largely unknown whether the caloric restriction phenomenon observed in animals would hold true for humans.

Epidemiologists at Brigham and Women’s Hospital, Harvard Medical School, looked at cancer incidence in a cohort of 7,303 Swedish women with a history of hospitalization for anorexia nervosa prior to age 40, comparing this with the cancer incidence in the general Swedish female population.

The contrast was striking. Women with histories of anorexia prior had a 53% lower incidence of breast cancer compared with the general population. Nulliparous women with a history of anorexia had a 23% lower incidence compared with nulliparous non-anorexic women. Parous women with histories of anorexia had a 76% lower incidence compared with age-similar parous women in the general healthy population (Michels KB, Ekbom A. JAMA. 2004; 291(10):1226–30).

These data should not, of course, be misinterpreted to suggest that anorexia or under-nutrition is healthy in any way. Breast cancer prevention should never be used as a rationale to justify anorexic behavior. But in the genome era, it is important that we not lose sight of the profound impact that diet, lifestyle and early-life habits can have on later diseases like cancer.

Overall, research on the link between diet and breast cancer has led to a lot of confusion, particularly regarding the association between dietary fat and breast cancer risk. It is important to realize that dietary fat intake is not necessarily related to caloric intake, though it serves as a good general marker.

One reason for the confusing, sometimes conflicting conclusions may be that most such studies are focused almost exclusively on adult diets rather than diets during youth. This has certainly confounded our conclusions about soy and breast cancer. The association between soy consumption and reductions in breast cancer is shown far more clearly in studies focused on early-in-life soy consumption. Studies of adult soy intake have shown very inconsistent results.

As the Swedish anorexia study shows so clearly, eating patterns in youth can have profound impact on later health. The message is clear that young girls should be educated about healthy nutrition, and afforded the opportunity to have healthier food options, while reducing intake of high-fat, low-nutrient junk foods.

Calcium–Vitamin D Supplements Prevent Bone Loss in Perimenopausal Women

Calcium and vitamin D supplements increase bone mineral density (BMD) in perimenopausal women, according to a recent randomized, double-blind, placebo-controlled trial. A total of 120 women aged 45–55 years, received daily dietary supplements of calcium (500 mg) plus vitamin D (200 IU), or placebo. The investigators assessed dietary calcium and vitamin D, as well as total body BMD at baseline and again at 15 and 30 months.

At 30 months, the women on calcium–vitamin D had significant increases in total BMD, with the mean total body BMD rising from 1.101 g/cm² at baseline to 1.111 g/cm². The placebo group lost BMD, from 1.102 g/cm² to 1.098 g/cm². Dietary intake of calcium and vitamin D did not change in either group during the study (Daniele N, et al. Pharmacol Res. 2004; 50:637–41).

Adequate calcium and vitamin D intake helps to prevent early bone loss in perimenopausal and early post-menopausal women. This is important, because the perimenopausal and early menopausal years are a key period for bone loss. Rates of bone loss are typically around 2% per year for the first 4 years of menopause. If we can slow this process early on, we can prevent osteoporosis.

There are important issues that the Daniele study did not address. We do not know what the baseline calcium and vitamin D intakes were in the population studied, so we do not know if the women were deficient at the outset. We also do not know the results for total bone mineral content. One of the things that were not controlled for was weight or body fat. Differences between the two groups on these parameters would impact the results.

All in all though, the findings reinforce the recommendation that women need to consume adequate levels of calcium and vitamin D. Those who do not obtain adequate levels in their diets really should be taking supplements.