to the editor: We were very interested to read this update on breast cancer treatment. Although the authors presented an excellent review of the oncologic and surgical considerations in the management of breast cancer, we feel there was a missed opportunity to educate primary care physicians on research supporting the benefits of complementary and alternative interventions, such as stress reduction, acupuncture, and yoga.

Mindfulness-based stress reduction is an eight-week standardized intervention based on a validated curriculum. The curriculum includes mindfulness meditation, relaxation training, and hatha yoga techniques, and has been shown to improve multiple end points in a variety of disease states. A recent randomized controlled trial (RCT) showed that mindfulness-based stress reduction resulted in a significant reduction in depression and anxiety levels and an improvement in energy and physical functioning in patients with breast cancer.¹ A critical review of published literature found consistent improvement in psychological functioning, reduced stress symptoms, and enhanced coping and well-being in outpatients with cancer who participated in mindfulness-based stress reduction.²

Acupuncture has been studied extensively and has shown a significant benefit in reducing postoperative pain,³ chemotherapy-associated vomiting,⁴ and hot flashes associated with anti-estrogen treatment⁵ in patients with breast cancer. A recent RCT compared acupuncture with venlafaxine (Effexor) in patients with hormone receptor–positive breast cancer and found that both interventions reduced vasomotor symptoms equally well, but acupuncture had no adverse effects and a longer sustained benefit, as well as the advantage of increasing sex drive and energy levels.⁵

A recent RCT involving yoga demonstrated a significant improvement in social functioning and emotional and spiritual well-being in patients with breast cancer who participated in a 12-week yoga intervention.⁶

Breast cancer often is an overwhelming and anxiety-provoking diagnosis. Most patients will seek information about complementary therapies as they proceed with conventional cancer treatment options. Therefore, primary care physicians should become familiar with the entire spectrum of effective interventions for these patients.

to the editor: This is an excellent article on the treatment of breast cancer. Unfortunately, it fails to address the positive effects of physical activity and fitness. Recent studies highlight the beneficial association of physical activity and fitness with a markedly decreased risk of initial and recurrent breast cancer in women of all ages.^1,2 The results of one prospective study are particularly convincing because the participants' fitness levels were measured with treadmill exercise stress testing rather than self-reporting, the latter of which tends to exaggerate leisure time activity and does not account for other types of activity (or lack thereof) in participants' daily lives.¹

in reply: We appreciate the interest in our review on the treatment of breast cancer. Both of these letters make excellent points regarding the importance of understanding the potential benefits of complementary and alternative interventions as adjuncts to conventional medical, surgical, and radiation therapies for breast cancer. One of our roles as family physicians is to be a resource to our patients about their treatment options as they are making decisions about initial treatment and as they are learning to live with cancer.

As the letter authors detail, some well-conducted studies have found decreased depression and anxiety and increased energy and physical functioning in patients using mindfulness-based stress reduction, and improved social functioning and a sense of well-being in patients doing yoga. A systematic review of randomized trials was unable to conclude that exercise during adjuvant treatment for breast cancer improved fatigue or other treatment-related adverse effects.¹

The improved prognosis for women diagnosed with early breast cancer makes helping women live the best life they can with cancer a fertile ground for research into complementary as well as conventional therapies.