HIV and cervical cancer

The cervix is the lower part of the uterus (womb) that connects the uterus to the vagina (birth canal). Cervical cancer develops when the cells in the cervix become abnormal and start to grow uncontrollably. The tissue that results from this growth is called a tumor.

According to the American Cancer Society, a viral infection called the human papillomavirus (HPV) causes about 90% of all cervical cancers. HPV describes a group of viruses that includes more than 100 different types. More than 30 of these viruses are sexually transmitted, and they can infect the genital area of both men and women. However, most people who have healthy immune systems experience no symptoms of the virus. Currently, there is no cure for HPV.

Since HIV weakens the body's immune system, women who are HIV-positive are more likely to develop HPV than women who are not HIV infected. Therefore, HIV-positive women have an increased risk of developing cervical cancer as well.

Before cervical cancer develops, cells in the cervix go through several changes over many years. Eventually, these pre-cancerous cells form a lesion called dysplasia (abnormal cellular growth), or a squamous intraepithelial lesion (SIL). These abnormal cells can also be described as CIN (cervical intraepithelial neoplasia). Moderate to severe dysplasia may be called carcinoma in situ or non-invasive cervical cancer.

Most women have no symptoms until the cancer invades healthy tissue. At this point, the cancer is described as invasive. Cervical cancer can be fatal, especially if it is not detected in the early stages.

Women are encouraged to have yearly pap smears at the doctor's office, which can detect pre-cancerous cells before the cancer is widespread.

Since 1993, cervical cancer has been classified as an AIDS-defining illness. This means that when HIV-infected patients develop cervical cancer, their condition has progressed to AIDS.

In June 2006, the U.S. Food and Drug Administration (FDA) approved the first HPV vaccine called Gardasil©. However, the safety and effectiveness of Gardasil© in HIV-positive people have not been determined. The drug, developed by Merck & Co., Inc., is a recombinant vaccine, which means that the vaccine does not contain the live virus, and there is no chance that patients who receive the vaccine can become infected HPV. The vaccine is given as three injections over the course of six months. The vaccine is expected to prevent most cases of cervical cancer due to HPV types included in the vaccine. However, patients will not be protected if they have been infected with the HPV type(s) prior to vaccination, and the drug does not protect against less common types of HPV.

Vagina: The vagina, also known as the birth canal, is the female reproductive organ. This muscular canal leads from the uterus (womb) to the exterior of the female body.

Vulva: The term vulva refers to the female's external genitalia, including the labia, clitoris and vaginal opening.

Uterus: The uterus, also known as the womb, is the pear-shaped female reproductive organ in which a fertilized egg is implanted and a fetus develops. This hollow, thick-walled organ is about the size of a fist. The uterus has three parts - the body (upper part), the isthmus (narrow central area), and the cervix (the lower portion).

Cervix: The cervix is the lower portion of the uterus that protrudes like a bottleneck into the vagina and dilates during labor to allow the passage of the fetus.

Human papilomavirus (HPV): A viral infection called the human papilomavirus causes about 90% of all cervical cancers. There are more than 100 types of HPV, and about 30 can be sexually transmitted through oral, anal or vaginal sex. About half of the sexually transmitted HPVs are associated with cervical cancer because they produce a protein that can cause cervical cells to grow uncontrollably. The virus produces a second protein that interferes with tumor suppressors that are usually produced by the body's immune system to control the growth of cells. The HPV-16 strain is thought to be a cause of about 50% of cervical cancers.

Women who have HIV have weakened immune systems because the virus infects the body's CD4 cells (helper T-cells that help destroy foreign substances that enter the body). Therefore, HIV-infected woman are more likely than non-infected women to develop HPV. This also means that HIV-infected women have a greater chance of developing cervical cancer than non-infected women.

In addition, women who engage in sexual behavior that puts them at risk for developing HIV (such as unprotected sex or having sex with multiple partners) also puts them at risk for developing HPV that could lead to cervical cancer.

Smoking: Women who smoke are twice as likely to develop cervical cancer than non-smokers. HIV patients who smoke have an even greater chance of developing cervical cancer. Tobacco smoke produces chemicals that can damage the DNA of cervical cells, which may eventually lead to cancer. Women who are HIV-infected have impaired immune systems that are unable to correct these pre-cancerous cells.

Most women are asymptomatic (experience no symptoms) until the cancer has become invasive (invades healthy tissue). Once the cancer has spread, common symptoms include unusual vaginal discharge, light vaginal bleeding (at times other than during menstruation), pain or vaginal bleeding during sexual intercourse and post-menopausal vaginal bleeding. Once the cancer has spread to the tissue near the cervix, the patient may experience pelvic pain and heavy vaginal bleeding.

General: Pap smear tests can detect pre-cancerous cells that may indicate cervical cancer. After an abnormal pap smear, a biopsy may be performed to definitively determine whether the patient has cervical cancer.

Pap test: In most cases, cervical cancer is detected after a Pap test is performed as part of a regular pelvic examination. During the procedure, the healthcare provider spreads open the vagina with a tool called a speculum. Then a swab is inserted into the vagina and rubbed against the cervix. The swab removes a small sample of mucus and cells from the cervix. The sample is analyzed under a microscope for pre-cancerous cells.

A negative Pap test means that there are no abnormalities in the cervical tissue, while a positive test indicates that abnormalities are present. These abnormalities can be described as either low-grade or high-grade squamous intraepithelial lesion (SIL), depending on the extent of dysplasia (abnormal cells). Researchers estimate that about 5-10% of Pap test show signs of mild abnormalities. However, many factors other than cervical cancer, including inflammation from bacteria or yeast infections, can cause abnormalities to appear. If an infection is present, the Pap test is repeated a few months after the infection is treated.

Biopsy: After an abnormal Pap test, the physician may need to perform a procedure called a biopsy. During this procedure, the doctor inserts a magnifying scope into the vagina to view the surface of the cervix. The physician then uses a swab to coat the cervix with an iodine solution, which will turn normal cells brown and abnormal cells white or yellow. This part of the procedure is called a Schiller test. If abnormal cells are seen, a colposcopic biopsy is performed.

During a colposcopic biopsy, the doctor removes a small piece of tissue from the cervix with a needle. The tissue is then examined for cancerous cells. This procedure may be performed with a local anesthetic (medication that numbs the region it is applied to). The procedure may cause mild cramping and bleeding, but it does not affect fertility.

A procedure called endocervical curettage biopsy may also be used to diagnose cervical cancer. During the procedure, a narrow instrument called a curette is used to scrape tissue from inside the opening of the cervix. A local anesthetic may be applied to the cervix. Patients may experience mild cramping or light bleeding after the procedure, but it does not affect fertility.

There are also several different types of cone biopsies, which are used to determine whether the abnormal cells have invaded the surface below the cervix. These procedures may also be used to treat many pre-cancers and very early cancers. A cone biopsy, or conization, is used to remove a cone-shaped piece of tissue from the cervix. During a cold knife cone biopsy, a surgical scalpel or laser is used to remove the tissue sample. A loop electrosurgical excision procedure (LEEP) is a cone biopsy that involves a wire that is heated by an electrical current. Cone biopsies are performed in a hospital, but an overnight stay is unnecessary. Patients may experience some cramping and bleeding for several weeks after the procedure is performed, but it does not affect fertility.

General :

Once a diagnosis of cervical cancer is confirmed, the healthcare provider will determine how much the cancer has spread. Treatment options and prognosis vary depending on the stage of the disease. This process is called staging. The International Federation of Gynecologists and Obstetricians (FIGO) system is usually used to stage cervical cancer.

Stage 0 :

Early cancer cells that are restricted to a very local area are present in the layer of cells that line the cervix. This type of cancer is called carcinoma in situ. These cells are non-invasive because they have not invaded healthy tissues.

Stage I :

The cancer has spread into the deeper tissues of the cervix, called the connective tissue. The cancer is limited to the uterus.

Stage IA: There is a very small cancerous area that is only visible with a microscope.

Stage IA1: The area containing cancer cells is less than 3mm deep and 7mm wide.

Stage IA2: The area containing cancer cells is 3-5mm deep and less than 7mm wide.

Stage IB: The cancer can be seen without a microscope, or it is deeper than 5mm or wider than 7mm.

Stage IB1: The cancer is no larger than 4cm.

Stage IB2: The cancer is larger than 4cm.

Stage II :

The cancer has spread from the cervix, but it is confined to the pelvic region (tissues surrounding the uterus). If treated, between 70-90% of patients who are diagnosed with Stage II cervical cancer will survive at least five years.

Stage IIA: The cancer has not spread into the uterus, but it may have spread down into upper region of the vagina. However, cancer is not present in the lower one-third of the vagina.

Stage IIB: The cancer has spread to the parametrial tissue (narrow, outer end of the uterus), which is adjacent to the cervix.

Stage III :

The cancer has spread to the lower one-third of the vagina, or it has entered the wall of the pelvis and may be blocking the ureters (tubes that carry urine from the kidneys to the bladder). If treated, between 30-50% of patients who are diagnosed with stage III cervical cancer survive at least five years.

Stage IIIA: The cancer has spread to the lower vagina, but it is not present in the pelvic wall.

Stage IIIB: The cancer has spread to the pelvic wall and/or is blocking the flow of urine through the ureters to the bladder.

Stage IV : Stage IV cervical cancer is the most advanced stage. During this stage, the cancer has spread to other parts of the body. Between 15-30% of women who have stage IV cervical cancer survive at least five years after diagnosis.

Stage IVA: The cancer has spread to the bladder or rectum.

Stage IVB: The cancer has spread to distant organs, such as the lungs.

Recurrent :

After cancer treatment is completed, the cancer has returned to the cervix or another part of the body.

General: Patients should tell their healthcare providers if they are taking any drugs (prescription or over-the-counter), herbs or supplements. Complementary or alternative therapies should not replace conventional treatments that have proven to effectively treat cervical cancer.

Pre-cancer and carcinoma in situ : A cold knife cone biopsy (surgical scalpel or laser is used to remove the abnormal tissue), loop electrosurgical excision procedure (cone biopsy that is performed with a wire that is heated by an electrical current), cryosurgery (freezing the cells with a metal probe), cauterization or diathermy (burning off the cancerous cells) and laser surgery (burning off the cancerous cells with a laser beam) have been used to treat cancer that is confined to the surface of the cervix (Stage 0) or other early-stage cervical cancers in women who may want to become pregnant. They can be used in combination with other treatments.

These procedures may cause bleeding or cramping. All of these treatments require close follow-up to detect any recurrence of the cancer.

Hysterectomy: A simple hysterectomy (surgical removal of the uterus) is used to treat some stages 0 and IA cervical cancers. In most cases, only the uterus is removed. However, sometimes the fallopian tubes and ovaries are removed as well. The tissues adjacent the uterus, including the vagina, remain intact. The uterus may be removed either through the abdomen or the vagina. Women who undergo a simple hysterectomy can no longer become pregnant.

A radical hysterectomy has been used to treat stages IA2, IB and IIA cervical cancers, especially in young women. During the procedure, the uterus and adjacent tissues, including the ovaries, the upper region of the vagina near the cervix and the pelvic lymph nodes, are surgically removed. Most radical hysterectomies involve abdominal surgery. However, it can be performed vaginally, in combination with a laparoscopic pelvic lymph node dissection (surgical removal of tissues). During a laparoscopy, a tube is inserted through a surgical incision and the lymph nodes are removed.

After a hysterectomy is performed, the tissue is examined to determine whether the cancer has spread and requires additional treatment.

Women who have had hysterectomies cannot become pregnant. Women who have had their fallopian tubes and ovaries removed will no longer experience menstruation, and they typically experience a decreased sex drive. This is because the ovaries produce the female hormones (estrogen and progesterone), which are responsible for menstruation and libido.

Pelvic exenteration (extensive surgery): Patients who experience recurrent cervical cancer that does not respond to other treatments may undergo pelvic exenteration (extensive surgery). This procedure includes a radical hysterectomy, in addition to the removal of the bladder, rectum, part of the colon and/or the entire vagina. These operations require the creation of new opening for the urine and feces. A new vagina may be created surgically. In many cases the external genitals, including the clitoris, remain intact.

Recovery from a pelvic exenteration may take anywhere from six months to two years. This treatment is successful with 40-50% of recurrent cervical cancers that are confined to the pelvis. If the recurrent cancer has spread to other organs, radiation or chemotherapy may be used to destroy cancer cells by preventing them from growing and multiplying.

Radiation therapy: Radiation therapy is often is used for treating stages IB, IIA and IIB cervical cancers, or in combination with surgery. The therapy involves the use of high-dosage X-rays or other high-energy waves to kill cancer cells. There are several different types of radiation therapy. External-beam radiation therapy uses rays that focus on the pelvic area from a source outside the body. Implant or internal radiation therapy involves a pellet of radioactive material that is placed internally, near the tumor. Alternatively, thin needles may be used to insert the radioactive material directly into the tumor.

Not all patients respond to radiation therapy. In addition, cervical cancer returns in about one-third of all women who are treated for advanced cervical cancer, usually within two years after therapy.

Common side effects of radiation therapy include skin reaction in the area of treatment, fatigue, upset stomach, loose bowels, premature menopause in young women, problems with urination and vaginal stenosis (narrowing of the vagina due to build-up of scar tissue), which may cause painful sexual intercourse.

Chemotherapy: Chemotherapy involves the use of one or more drugs that kill cancer cells. Cervical cancer patients receive chemotherapy when the cancer has spread beyond the cervix. The treatment is usually used after surgery or radiation treatment. Stages IIB, III, IV and recurrent cervical cancers are usually treated with a combination of external and internal radiation, as well as chemotherapy. Commonly used chemotherapy drugs for cervical cancer include cisplatin (Platinol©-AQ), ifosfamide (Ifex©) and fluorouracil (Adrucil©). These may be injected or taken orally. The National Cancer Institute recommends that chemotherapy with cisplatin (Platinol©-AQ) be considered for all women who receive radiation therapy for cervical cancer.

Chemotherapy side effects depend on the type of drug, dose and length of treatment. Common symptoms include nausea and vomiting, fatigue, changes in appetite, hair loss, mouth or vaginal sores, infections, menstrual cycle changes, premature menopause, infertility and anemia (low red blood cell count). With the exception of menopause and infertility, most of the side effects are temporary and resolve once the treatment is completed.

Good scientific evidence :

Greater celandine : Ukrain™, a semisynthetic drug derived from greater celandine (Chelidonium majus), has been studied in clinical trials of various types of cancer with consistently positive outcomes. However, the quality of the research performed to date is inadequate, and higher quality studies are needed.

Use cautiously in patients taking amphetamines, morphine, hexobarbital, MAOIs, or dopaminergic or serotonergic drugs, or in patients undergoing radiation therapy. Avoid in patients with liver disease or in pregnant and lactating women.

Guided imagery : Early research suggests that guided imagery may help reduce cancer pain. Further research is needed to confirm these results.

Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified health care provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety or emotional upset because imagery may trigger these symptoms. If feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse, speak with a qualified health care provider before practicing guided imagery.

Meditation : There is good evidence that various types of meditation may help improve quality of life in cancer patients. Studies have shown benefits for mood, sleep quality, and the stresses of treatment. The specific effects of meditation are not fully understood. Additional research is needed in this area.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

Psychotherapy : Psychotherapy is an interactive process between a person and a qualified mental health care professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). There is good evidence that psychotherapy may enhance quality of life in cancer patients by reducing emotional distress and aiding in coping with the stresses and challenges of cancer. Therapy may be supportive-expressive therapy, cognitive therapy or group therapy. While some patients seek psychotherapy in hopes of extending survival, there conclusive evidence of effects on medical prognosis is currently lacking. Psychotherapy may help people come to terms with the fact that they may die of cancer, which is the 4th stage of dealing with a terminal illness, including denial, anger, bargaining, and acceptance.

Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.

Yoga : Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Several studies report enhanced quality of life in cancer, lower sleep disturbance, decreased stress symptoms and changes in cancer-related immune cells after patients received relaxation, meditation and gentle yoga therapy. Yoga is not recommended as a sole treatment for cancer but may be helpful as an adjunct therapy.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Unclear or conflicting scientific evidence :

Acupuncture : Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. There has been limited research on acupuncture for cancer pain, and the research that was done was shown to have mixed results. More studies are needed to determine potential benefits. Evidence from several small studies supports use of acupuncture at a specific point on the wrist (P6) to help chemotherapy patients reduce nausea and vomiting. Acupuncture may also reduce the pain associated with cancer.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Aloe : Transparent gel from the pulp of the meaty leaves of Aloe vera has been used on the skin for thousands of years to treat wounds, skin infections, burns, and numerous other skin conditions. Dried latex from the inner lining of the leaf has traditionally been used as an oral laxative. Preliminary research suggests that aloe may help in the area of cancer prevention or may aid in the regression of cancerous tumors. Additional research is needed in this area.

Caution is advised when taking aloe supplements as numerous adverse effects including a laxative effect, cramping, dehydration and drug interactions are possible. Aloe should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

American pawpaw : Evidence supporting the use of the American pawpaw (Asimina triloba) tree for cancer treatment in humans is largely anecdotal and subjective. However, use in humans has reported minimal side effects, and evidence from animal and test tube studies suggest that American pawpaw extract does have some anticancer activity. Pawpaw standardized extract has been used for 18 months in patients with various forms of cancer. Well-designed studies on the long-term effects of pawpaw extracts are currently lacking. Pawpaw should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Antineoplastons : Antineoplastons are a group of naturally occurring peptide fractions, which were observed by Stanislaw Burzynski, MD, PhD in the late 1970s to be absent in the urine of cancer patients. There is inconclusive scientific evidence regarding the effectiveness of antineoplastons in the treatment of cancer. Several preliminary human studies (case series, phase I/II trials) have examined antineoplaston types A2, A5, A10, AS2-1, and AS2-5 for a variety of cancer types. It remains unclear if antineoplastons are effective, or what doses may be safe. Until better research is available, no clear conclusion can be drawn.

Avoid if allergic or hypersensitive to antineoplastons. Use cautiously with high medical or psychiatric risk, an active infection due to a possible decrease in white blood cells, high blood pressure, heart conditions, chronic obstructive pulmonary disease, liver disease or damage, or kidney disease or damage. Avoid if pregnant or breastfeeding.

Arabinoxylan : Arabinoxylan is made by altering the outer shell of rice bran using enzymes from Hyphomycetes mycelia mushroom extract. Arabinoxylan has been found to improve immune reactions in patients with diabetes and cancer of various types. Arabinoxylan products may contain high calcium and phosphorus levels, which may be harmful for patients with compromised renal (kidney) function. Caution is advised when taking arabinoxylan supplements, as numerous adverse effects including drug interactions are possible. Arabinoxylan should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Aromatherapy : Healing with fragrant oils has been used for thousands of years. Aromatherapy is often used in people with chronic illnesses (frequently in combination with massage), with the intention to improve quality of life or well-being. There is currently not enough scientific evidence to form a firm conclusion about the effectiveness of aromatherapy for quality of life in cancer.

Essential oils should only be used on the skin in areas without irritation. Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving or operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.

Art therapy : Art therapy involves the application of a variety of art modalities including drawing, painting, clay and sculpture. Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. Limited evidence suggests that art therapy may be of benefit in cancer caregiving for families of cancer patients. Possible benefits include reduced stress, lowered anxiety, increased positive emotions and increased positive communication with cancer patients and health care professionals. Art therapy may also reduce pain and other symptoms in cancer patients. More studies are needed to determine how best to use this form of intervention with this population. Art therapy may also benefit children hospitalized with leukemia during and after painful procedures. Limited available study suggests that art therapy improves cooperation with treatment. Children requested art therapy again when procedures were repeated, and parents reported that children were more manageable after art therapy.

Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.

Astragalus : Astragalus (Astragalus membranaceus) has been used in Chinese medicine for centuries for its immune enhancing properties. Although early laboratory and animal studies report immune stimulation and reduced cancer cell growth associated with the use of astragalus, reliable human evidence in these areas is currently lacking. In Chinese medicine, astragalus-containing herbal mixtures are also sometimes used with the intention to reduce side effects of chemotherapy and other cancer treatments. Astragalus-containing herbal combination formulas may also have beneficial effects in aplastic anemia. Due to a lack of well-designed research, a firm conclusion cannot be drawn.

Caution is advised when taking astragalus supplements, as numerous adverse effects including drug interactions are possible. Astragalus should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Baikal skullcap : Although the outcomes of early studies using baikal skullcap for cancer are promising, high-quality clinical studies are needed in this area before a conclusion can be made. Avoid if allergic or hypersensitive to Baikal skullcap (Scutellaria barbata), its constituents, or members of the Lamiaceae family. Use cautiously if taking sedatives and/or operating heavy machinery. Use cautiously if taking antineoplastic (anticancer) agents or agents metabolized by cytochrome P450 enzymes. Avoid if pregnant or breastfeeding. Baikal skullcap is an ingredient in PC-SPES, a product that has been recalled from the U.S. market and should not be used.

Bee pollen : Bee pollen is considered a highly nutritious food because it contains a balance of vitamins, minerals, proteins, carbohydrates, fats, enzymes, and essential amino acids. Research has found that bee pollen may reduce some adverse effects of cancer treatment side effects. Additional study is needed before a firm recommendation can be made. Caution is advised when taking bee pollen supplements as allergic reactions may occur in sensitive individuals. Bee pollen should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Beta-glucan : Treatment with a beta-glucan, called lentinan, plus chemotherapy (S-1) may help prolong the lives of patients with cancer that has returned or cannot be operated on. More research is needed in this area. Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucan is generally considered safe. Use cautiously with AIDS or AIDS-related complex (ARC). Avoid using particulate beta-glucan. Avoid if pregnant or breastfeeding.

Bitter melon : Bitter melon (Momordica charantia) is used in Avurvedic medicine from India to lower blood sugar levels. Research has also found that bitter melon extracts may be beneficial in cancer therapies. MAP30, a protein isolated from bitter melon extract, is reported to possess anti-cancer effects in laboratory studies. Potential anti-cancer effects have not been studied appropriately in humans. Caution is advised when taking bitter melon supplements, as numerous adverse effects including blood sugar lowering and drug interactions are possible. Bitter melon should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Black tea : Black tea (Camellia sinensis) is from the same plant as green tea, but the leaves are processed differently. Black tea usually contains more caffeine than green tea. Several studies have explored a possible association between regular consumption of black tea and rates of cancer in several populations. This research has yielded conflicting results, with some studies suggesting benefits, and others reporting no effects. Laboratory and animal studies report that components of tea, such as polyphenols, have antioxidant properties and effects against tumors. However, effects in humans remain unclear, and these components may be more common in green tea rather than in black tea. Some animal and laboratory research suggests that components of black tea may actually be carcinogenic, or cancer causing, although effects in humans are not clear. Overall, the relationship of black tea consumption and human cancer prevention remains undetermined.

Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use cautiously if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances/insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.

Bovine cartilage : In early study, bovine tracheal cartilage (preparations such as Catrix© and VitaCarte©) has been studied for the treatment of cancer with encouraging results. High quality clinical research is needed to better determine the effectiveness of bovine tracheal cartilage preparations for cancer treatment.

Avoid if allergic or hypersensitive to bovine cartilage or any of its constituents. Use cautiously with cancer, renal (kidney) failure, or hepatic (liver) failure. Avoid if pregnant or breastfeeding.

Bromelain : Bromelain is a sulfur-containing digestive enzyme (proteins which help with digestion) that is extracted from the stem and the fruit of the pineapple plant (Ananas comosus). There is not enough information to recommend for or against the use of bromelain in the treatment of cancer, either alone or in addition to other therapies. One small study found that a bromelain supplement decreased tumor size in 12 breast cancer patients. Patients took the supplements for different periods of time, lasting from months to years. Caution is advised when taking bromelain supplements, as numerous adverse effects including blood thinning and drug interactions are possible. Bromelain should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Cat's claw : Originally found in Peru, the use of cat's claw (Uncaria tomentosa) has been said to date back to the Inca civilization, possibly as far back as 2,000 years. Cat's claw has anti-inflammatory properties, and several low-quality studies suggest that cat's claw may slow tumor growth. However, this research is early and has not identified specific types of cancer that may benefit; thus, the results are not clear. A few studies suggest that cat's claw may also boost the immune system. Caution is advised when taking cat's claw supplements, as numerous adverse effects including blood thinning and drug interactions are possible. Cat's claw should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Chaparral : Chaparral was used by the Native Americans for various health conditions. The chaparral component nordihydroguaiaretic acid (NDGA) has been evaluated as a treatment for cancer but due to risk of toxicity is considered unsafe and not recommended for use. Chaparral and NDGA have been associated with cases of kidney and liver failure, liver cirrhosis, kidney cysts, and kidney cancer in humans. In response to these reports, the U.S. Food and Drug Administration (FDA) removed chaparral from its "generally recognized as safe" (GRAS) list in 1970. Chaparral and NDGA are generally considered unsafe and are not recommended for use.

Avoid if allergic to chaparral or any of its components, including nordihydroguaiaretic acid. Use cautiously if taking blood thinners (anticoagulants), blood sugar medication, or drugs that are broken down by the liver (like amiodarone, phenobarbital, valproic acid). Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if pregnant or breastfeeding.

Chlorophyll : Preliminary evidence in suggest that chlorophyll may aid in the reduction of side effects associated with photodynamic therapies, such as those used in management of malignant tumors. Further research is required to support the use of chlorophyll as a laser therapy adjunct for cancer treatment.

Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or antidiabetes agents. Avoid if pregnant or breastfeeding.

Chrysanthemum : Early study indicates that hua-sheng-ping (includes Chrysanthemum morifolium, Glycyrrhiza uralensis, and Panax notoginseng) may be beneficial for patients with precancerous lesions. However, more research is needed.

Avoid if allergic or hypersensitive to Chrysanthemum, its constituents, or members of the Asteraceae/Compositae family, such as dandelion, goldenrod, ragweed, sunflower, and daisies. Use cautiously if taking medication for gout, cancer, or HIV. Use cautiously with compromised immune systems or if taking immunomodulators. Avoid with photosensitivity or if taking photosensitizers. Avoid large acute or chronic doses of ingested pyrethrin. Avoid pyrethrin with compromised liver function, epilepsy, or asthma. Avoid ocular exposure to pyrethrin. Avoid if pregnant or breastfeeding.

Coenzyme Q10 : Further research is needed to determine if coenzyme Q10 (CoQ10) may be of benefit for cancer when used with other therapies.

Allergy associated with Coenzyme Q10 supplements has not been reported, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix©), or blood pressure, blood sugar, cholesterol or thyroid drugs. Avoid if pregnant or breastfeeding.

Copper : Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains and fruits, as well as shellfish, avocado, and beef (organs such as liver). Preliminary research reports that lowering copper levels theoretically may arrest the progression of cancer by inhibiting blood vessel growth (angiogenesis). Copper intake has not been identified as a risk factor for the development or progression of cancer. Copper is potentially unsafe when used orally in higher doses than the RDA. Copper supplements should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Cranberry : Several laboratory studies have reported positive effects of proanthocyanidins, flavonoid components of cranberry (Vaccinium macrocarpon) and other fruits such as blueberries, grape seed, and pomegranate, on health. Based on early laboratory research, cranberry has been proposed for cancer prevention. Additional study is needed in humans before a conclusion can be made.

Avoid if allergic to cranberries, blueberries or other plants of the Vaccinium species. Sweetened cranberry juice may effect blood sugar levels. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.

Dandelion : Limited animal research does not provide a clear assessment of the effects of dandelion on tumor growth. Well-conducted human studies are needed to better determine dandelion's effects on cancer.

Avoid if allergic to chamomile, feverfew, honey, yarrow, or any related plants such as aster, daisies, sunflower, chrysanthemum, mugwort, ragweed, or ragwort. Use cautiously with diabetes or bleeding disorders, gastroesophageal reflux disease (GERD), kidney or liver diseases, or a history of stroke or electrolyte disorders. Monitor potassium blood levels. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

DHEA (Dehydroepiandosterone) : DHEA (dehydroepiandrosterone) is an endogenous hormone (made in the human body) secreted by the adrenal gland that serves as a precursor to male and female sex hormones (androgens and estrogens). Initial research reports that the use of intravaginal DHEA may promote the regression of low-grade cervical cancer lesions. However, further study is necessary in this area before a conclusion can be made.

Patients should not substitute the use of DHEA for more established therapies, and should discuss management options and follow-up with a primary healthcare professional or gynecologist. Caution is advised when taking DHEA supplements due to adverse effects and possible drug interactions. DHEA should not be used in pregnancy or breastfeeding, unless otherwise directed by a doctor.

Echinacea : There is currently a lack of clear human evidence that echinacea affects any type of cancer. The evidence from a small number of clinical trials evaluating efficacy of echinacea in the treatment of radiation-induced leukopenia (decrease in white blood cells) is equivocal. Studies have used the combination product Esberitox©, which includes extracts of echinacea (Echinacea purpurea and pallida) root, white cedar (Thuja occidentalis) leaf, and wild indigo (Baptisia tinctoria) root. Additional clinical studies are needed to make a conclusion.

Caution is advised when taking echinacea supplements, as numerous adverse effects including drug interactions are possible. Echinacea should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Essiac© : Essiac© contains a combination of herbs, including burdock root (Arctium lappa), sheep sorrel (Rumex acetosella), slippery elm inner bark (Ulmus fulva), and Turkish rhubarb (Rheum palmatum). The original formula was developed by the Canadian nurse Rene Caisse (1888-1978) and is thought to be effective in cancer therapies, although currently there is not enough evidence to recommend for or against the use of this herbal mixture as a therapy for any type of cancer. Different brands may contain variable ingredients, and the comparative effectiveness of these formulas is not known. None of the individual herbs used in Essiac© has been tested in rigorous human cancer trials, although some components have anti-tumor activity in laboratory studies. Numerous individual patient testimonials and reports from manufacturers are available on the Internet, although these cannot be considered scientifically viable as evidence. Individuals with cancer are advised not to delay treatment with more proven therapies. Caution is advised when taking Essiac© supplements, as numerous adverse effects including drug interactions are possible. Essiac© should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Focusing : Focusing (experiential therapy) is a method of psychotherapy that involves being aware of one's feelings surrounding a particular issue and understanding the meaning behind words or images conveyed by those feelings. Early evidence suggests focusing may improve mood and attitude in cancer patients. Firm recommendations cannot be made until well-designed clinical trials are available.

Side effect reporting is rare, but patients should consult with a qualified healthcare practitioner before making decisions about medical conditions and practices. Individuals with severe emotional difficulties should not abandon proven medical and psychological therapies but rather choose focusing as a possible adjunct.

Folic acid : Folic acid or folate is a form of a water-soluble B vitamin needed for human health. Preliminary evidence suggests that folate may decrease the risk of several types of cancer. Additional research is needed to make a conclusion. Folic acid supplementation may mask the symptoms of pernicious, aplastic, or normocytic anemias caused by vitamin B12 deficiency and may lead to neurological damage.

Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents and with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.

Gamma linolenic acid (GLA) : GLA is an omega-6 essential fatty acid. Some laboratory and human studies indicate that GLA may have anti-tumor activity and may be used as a cancer treatment adjunct. Additional research is needed in this area.

Caution is advised when taking GLA supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. GLA should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Garlic : Preliminary human studies suggest that regular consumption of garlic (Allium sativum) supplements may reduce the risk of developing several types of cancer. Some studies use multi-ingredient products so it is difficult to determine if garlic alone may play a beneficial role in cancer prevention. Further well-designed human clinical trials are needed to conclude whether eating garlic or taking garlic supplements may prevent or treat cancer.

Caution is advised when taking garlic supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Garlic should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Ginseng : Early studies report that ginseng taken by mouth may be of benefit in cancer prevention, especially if ginseng powder or extract is used. Weak studies suggest that ginseng in combination with other herbs may improve cell activity, immune function, and red and white blood cell counts in patients with aplastic anemia; however, other studies have found decreases in blood cell counts. Early studies suggest that ginseng may decrease radiation therapy side effects and may be used as a chemotherapy adjunct to improve body weight, quality of life, and the immune response. There is currently not enough evidence to recommend the use of Panax ginseng or American ginseng for these indications. Study results are unclear, and more research is needed before a clear conclusion can be reached.

Caution is advised when taking ginseng supplements, as numerous adverse effects including an increased risk of drug interactions are possible. Ginseng should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Goji : Polysaccharide constituents, such as alpha- and beta-glucans from a variety of plants, are reported to have immune system enhancing properties. In clinical study, Lycium barbarum polysaccharides (LBP) demonstrated a synergistic effect in various cancer treatments, when administered in conjunction with powerful immune stimulating drugs.

Use cautiously in patients who are taking blood-thinning medications, such as warfarin. Use cautiously in asthma patients and in patients with sulfite sensitivities. The New York Department of Agriculture has detected the presence of undeclared sulfites, a food additive, in two dried goji berry products from China. Avoid in patients who are allergic to goji, any of its constituents, or to members of the Solanaceae family.

Grape seed : There is currently little information available on the use of grape seed extract in the treatment of human cancer. Further research is needed before a recommendation can be made.

Avoid if allergic or hypersensitive to grapes or other grape compounds. Use cautiously with bleeding disorders or if taking blood thinners such as warfarin, aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), or anti-platelet agents. Use cautiously with drugs processed using the liver's cytochrome P450 enzyme system. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Avoid if pregnant or breastfeeding.

Green tea : Green tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Green tea has a long history of use in health and longevity, dating back to China approximately 5,000 years ago. Although used for centuries to help prevent diseases, the relationship of green tea consumption and human cancer in general remains inconclusive. Evidence from well-designed clinical trials is needed before a firm conclusion can be made in this area.

Caution is advised when taking green tea supplements, as numerous adverse effects including an increased risk of drug interactions are possible. Green tea should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Healing touch : Preliminary data suggests that healing touch (HT) may increase quality of life in cancer. However, due to weaknesses in design and the small number of studies, data are insufficient to make definitive recommendations. Studies with stronger designs are needed. HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.

Hoxsey formula : "Hoxsey formula" is a misleading name, because it is not a single formula, but rather is a therapeutic regimen consisting of an oral tonic, topical (on the skin) preparations, and supportive therapy. The tonic is individualized for cancer patients based on general condition, location of cancer, and previous history of treatment. An ingredient that usually remains constant for every patient is potassium iodide. Other ingredients are then added and may include licorice, red clover, burdock, stillingia root, berberis root, pokeroot, cascara, Aromatic USP 14, prickly ash bark, and buckthorn bark. A red paste may be used, which tends to be caustic (irritating), and contains antimony trisulfide, zinc chloride, and bloodroot. A topical yellow powder may be used, and contains arsenic sulfide, talc, sulfur, and a "yellow precipitate." A clear solution may also be administered, and contains trichloroacetic acid.

Well-designed human studies available evaluating the safety or effectiveness of Hoxsey formula are currently lacking. Caution is advised when taking the Hoxsey formula supplements, as numerous adverse effects including an increased risk of drug interactions are possible. Hoxsey formula should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Hydrazine sulfate : Hydrazine is an industrial chemical marketed as having the potential to repress weight loss and cachexia (muscle wasting) associated with cancer, and to improve general appetite status. However, in large randomized controlled trials, hydrazine has not been proven effective for improving appetite, reducing weight loss, or improving survival in adults. The National Cancer Institute (NCI) sponsored studies of hydrazine sulfate that claimed efficacy in improving survival for some patients with advanced cancer. Trial results found that hydrazine sulfate did not prolong survival for cancer patients. The U.S. Food and Drug Administration (FDA) has received requests from individual physicians for approval to use hydrazine sulfate on a case-by-case "compassionate use" basis on the chance that patients with no other available effective cancer treatment options might benefit from this therapy. The overall controversy in the use of hydrazine sulfate is ongoing, and relevance to clinical practice is unknown. The use of hydrazine sulfate needs to be evaluated further before any recommendations can be made.

Hydrazine sulfate may cause cancer. Avoid if allergic or hypersensitive to hydrazine sulfate or any of its constituents. Use cautiously with liver or kidney problems, psychosis, diabetes or seizure disorders. Avoid if pregnant or breastfeeding. Side effects have been reported, including dizziness, nausea, and vomiting.

Iodine : Iodine is an element (atomic number 53), which is required by humans for the synthesis of thyroid hormones (triiodothyronine/T3 and thyroxine/T4). The potential role of non-radioactive iodine in cancer care remains unknown. Antioxidant and anti-tumor effects have been proposed based on laboratory research. In contrast, some scientists have asserted that tumors may uptake more iodine than normal tissues. It has been suggested that high rates of gastric (stomach) cancer or low rates of breast cancer in coastal Japan may be due to high iodine intake, although this has not been demonstrated scientifically. Povidone-iodine solutions have been used as a part of alternative cancer regimens, such as the Hoxsey formula. Preliminary study has also indicated povidone-iodone solution as a potential rectal washout for rectal cancer. Overall, no clear conclusion can be drawn based on the currently available evidence.

Reactions can be severe, and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis, or tuberculosis. Use cautiously when applying to the skin because it may irritate/burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.

Jiaogulan : Preliminary evidence indicates that gypenosides extracted from Gynostemma pentaphyllum may decrease cancer cell viability, arrest the cell cycle, and induce apoptosis (cell death) in human cancer cells. Immune function in cancer patients has also been studied. Additional study is needed in this area.

Avoid if allergic or hypersensitive to jiaogulan (Gynostemma pentaphyllum), its constituents, or members of the Cucurbitaceae family. Use cautiously with blood disorders or taking anticoagulants or anti-platelet drugs (blood thinners). Use cautiously with diabetes. Avoid if pregnant or breastfeeding.

Lavender : Perillyl alcohol (POH), derived from lavender (Lavendula officinalis), may be beneficial in the treatment of some types of cancer. Preliminary small studies in humans, involving the use of POH suggest safety and tolerability, but effectiveness has not been established.

Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

Lutein : Currently, there is insufficient available evidence to recommend for or against the use of lutein for cancer. Available evidence in humans is conflicting.

Avoid if allergic or hypersensitive to lutein or zeaxanthin. Use cautiously if at risk for cardiovascular disease or cancer. Avoid if pregnant or breastfeeding.

Lycopene : High levels of lycopene are found in tomatoes and in tomato-based products. Tomatoes are also sources of other nutrients such as vitamin C, folate, and potassium. Several laboratory and human studies examining tomato-based products and blood lycopene levels suggest that lycopene may be associated with a lower risk of developing cancer and may help stimulate the immune system. However, due to a lack of well-designed human research using lycopene supplements, its effectiveness for cancer prevention remains unclear. Observations of large human populations suggest possible benefits of tomato product intake in cervical cancer prevention. However, other studies report no benefits. Research that specifically studies lycopene supplements is lacking.

Avoid if allergic to tomatoes or to lycopene. Due to a lack of conclusive data, avoid if pregnant or breastfeeding.

Maitake mushroom : Maitake is the Japanese name for the edible mushroom Grifola frondosa. Maitake has been used traditionally both as a food and for medicinal purposes. Early studies in the laboratory as well as in humans suggest that beta-glucan extracts from maitake may increase the body's ability to fight cancer. However, these studies have not been well designed, and better research is needed before the use of maitake for cancer can be recommended.

Caution is advised when taking maitake supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Maitake should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Meditation : Not enough research has shown meditation to be of benefit in cancer prevention. More studies are needed.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

Melatonin : There are several early-phase and controlled human trials of melatonin in patients with various advanced stage malignancies. There is currently not enough definitive scientific evidence to discern if melatonin is beneficial as a cancer treatment, whether it increases (or decreases) the effectiveness of other cancer therapies, or if it safely reduces chemotherapy side effects.

Melatonin is not to be used for extended periods of time. Caution is advised when taking melatonin supplements, as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding unless otherwise advised by a doctor.

Milk thistle : Milk thistle (Silybum marianum) has been used medicinally in China for over 2,000 years, most commonly for the treatment of liver and gallbladder disorders. There are early reports from laboratory experiments that the components silymarin and silibinin found in milk thistle may reduce the growth of human cancer cells. However, effects have not been shown in high-quality human trials.

Caution is advised when taking milk thistle supplements, as numerous adverse effects including an increased risk of bleeding and drug interactions are possible. Milk thistle should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Mistletoe : Mistletoe is one of the most widely used unconventional cancer treatments in Europe. Mistletoe extracts have been studied for a variety of human cancers as well as melanoma and leukemia. However, efficacy has not been conclusively proven for any one condition. In fact, some studies have shown lack of efficacy of certain preparations for a variety of cancers. Larger, well-designed clinical trials are needed.

Caution is advised when taking mistletoe supplements, as numerous adverse effects including nausea, vomiting, and drug interactions are possible. Mistletoe should not be used if pregnant or breast-feeding, unless otherwise directed by a doctor.

Moxibustion : Moxibustion is a healing technique employed across the diverse traditions of acupuncture and oriental medicine for over 2,000 years. Moxibustion uses the principle of heat to stimulate circulation and break up congestion or stagnation of blood and chi. Moxibustion is closely related to acupuncture as it is applied to specific acupuncture points. Preliminary evidence suggests that moxibustion may reduce side effects of chemotherapy or radiation therapy. More studies are needed.

Use cautiously over large blood vessels and thin or weak skin. Avoid with aneurysms, any kind of "heat syndrome," cardiac disease, convulsions or cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, inflammatory conditions, over allergic skin conditions or ulcerated sores, or skin adhesions. Avoid if pregnant or breastfeeding. Avoid areas with an inflamed organ, contraindicated acupuncture points, face, genitals, head, inflamed areas in general, nipples, and skin adhesions. Avoid in patients who have just finished exercising or taking a hot bath or shower. Use cautiously with elderly people with large vessels. It is considered not advisable to bathe or shower for up to 24 hours after a moxibustion treatment.

Pap tests: Most cases of cervical cancers are preventable, since they start with easily detectable precancerous changes. Therefore, the best prevention for cervical cancer is a regular Pap test. The American Cancer Society (ACS) revised its guidelines for regular screening in late 2002. Women should begin having Pap tests about three years after having sexual intercourse, but no later than 21 years of age. Women should receive yearly Pap tests until age 30. Once a woman has had three normal results in a row, she may get screened every two to three years. A doctor may suggest more frequent screening if a woman is at risk for cervical cancer. Women who have HPV infections or who smoke have an increased risk of developing cervical cancer. Women who have had total hysterectomies that include the removal of the cervix and those older than 70 who have had three normal results generally do not need to continue having Pap tests under the new guidelines.

Highly active antiretroviral therapy (HAART): Patients who are immunocompetent are less likely to acquire HPV. Therefore, it is recommended that HIV patients receive highly active antiretroviral therapy (HAART) to boost their immune systems.