Nutritional Support Strategies in Treatment
Cancer Immune/Antioxidant Support
Immune System Support
An optimally functioning immune system is essential for the body to address any disease including cancer- The following is an overview of specialized immune cells and components:
- Natural Killer (NK) cells are described as the "sentinel" cell in the immune system, because in healthy
individuals they are the first cells to encounter cancer cells, invading bacteria and virally infected cells. They can take on and kill multiple disease cells simultaneously and also have a regulatory effect on the rest of the immune system.
- Macrophages are the "Pac-men" of the immune system. They engulf disease cells, digest them and display fragments of the digested invader which become "antigens" that stimulate the appropriate B cell and T cell proliferation.
- Lymphocyte is a type of white blood cell that is long lived and carries memory of past infections. As they
mature they eventually turn into B and T cells.
- T cells are a class of lymphocytes (also called T lymphocytes) derived from the thymus that control cell
mediated immune reactions and the development of B cells. There are three fundamentally different types
of T cells: helper, killer and suppressor. Each has many subdivisions.
- B cells are a type of lymphocyte normally involved in the production of antibodies to combat infection. During infections, individual B cell clones multiply and are transformed into plasma cells, which produce large amounts of antibodies against particular antigen on a foreign microbe.
- Interleukin-12 is released by macrophages in response to infection and begins the process of
customizing immune system cells to suit the specific invader. It enhances the ability of Natural Killer (NK) cells to destroy microbes and cancer cells, induces interferon production and stimulates the production of activated T cells and NK cells.
- Interleukin-2 is a chemical messenger, a substance that can improve the body's response to disease. It stimulates the growth of certain disease-fighting blood cells in the immune system.
- Tumor Necrosis Factor (TNF) is released by macrophages and induces fever. It kills cancer cells and caused the production of lymphokines.
- Interferon refers to a family of glycoproteins derived from human cells which normally has a role in fighting viral infections by preventing multiplication in cells.
AHCC® (ImmPowerTM) Immune Support
AHCC is an extract of a unique hybridization of several medical mushrooms known for their immune enhancing abilities. On their own, each mushroom has a long medical history in Japan, where their extracts are widely prescribed by physicians. But when combined into a single hybrid mushroom, the resulting active ingredient is
so potent that dozens of rigorous scientific studies have now established AHCC to be one of the world's most powerful-and safe-immune stimulators.
In vitro, animal, and human studies confirm that AHCC effectively treats, and, in some cases, even prevents the reoccurrence of liver cancer, prostate cancer, multiple myeloma, breast cancer, AIDS, and other life-threatening conditions, with no dangerous side effects. In smaller doses, AHCC can also boost the immune function of healthy people, helping to prevent infections and promote well-being. Many health problems, including some that were previously thought to be unrelated to the immune system, are now known to result from some degree
of immune deficiency. Subtle to severe immune dysfunction can combine with other factors to cause many
illnesses, including:
- Gum disease Recurrent infections, such as colds, flu, and parasites
- Heart disease Peptic ulcer
- Cancer Slow healing wounds
- Digestive problems AIDS
- Multiple Sclerosis Auto-immune illnesses
- Stress associated illness Chronic Fatigue Syndrome
For years, conventional medicine has tried to cope with these and other conditions as separate illnesses, often relying on invasive and potentially dangerous disease-specific drugs, surgery, and other treatments. Not only has this approach yielded only moderate success, in many cases it has created additional health problems: chemotherapy side effects, surgical complications, drug reactions, super-resistant bacteria, and other problems that in some cases may be as bad as (or worse than) the specific disease. In fact, according to the Journal of the American Medical Association, (v279, April 1998) prescription medications kill more than 100,000 people a year, making adverse drug reactions the fourth leading cause of death in the United States.
The cutting edge in medicine today is to shift away from disease-specific interventions and to focus on the fundamental, underlying causes of health and disease: the proper functioning of interdependent body systems, such as the nervous system, the endocrine system and the immune system.
Research Finds Remarkable Immune System Boost in Multiple Ways
Several scientific studies of the extract of AHCC, published in respected peer-reviewed journals such as International Journal of Immunology, Anti-Cancer Drugs,and Society of Natural Immunity have established the health benefits and safety of AHCC more conclusively than nearly any other natural supplement. What is especially remarkable about AHCC is that it so consistently and effectively boosts immune system function in the following ways:
- It stimulates cytokine (IL-2, IL-12, TNRα and IFNα production, which act to stimulate immune function.
- It increases NK cell activity against diseased cells as much as 300 percent.
- It increases the formation of explosive granules within NK cells. The more ammunition each NK cell carries
the more invaders it can destroy.
- It increases the number and activity of lymphocytes, specifically increasing T cells by up to 200 percent.
- It increases Interferon levels, which inhibit the replication of viruses and stimulates NK cell activity.
- It increases the formulation of TNF, a group of proteins that help destroy cancer cells.
These dramatic immune effects translate into profound health benefits. A 1995 clinical trial, published in the International Journal of Immunotherapy showed that 3 grams of AHCC per day significantly lowered the level of tumor markers (substances that detect the presence of tumors) found in patients with several different types of cancer, including prostate cancer, ovarian cancer, multiple myeloma, and breast cancer. This study documented complete remissions in six of 11 patients and significant increases in NK cell activity in nine of 11 patients. T and
B cell activity levels also rose considerably.
No Side Effects Reported from AHCC
Unlike conventional cancer treatments, AHCC seems to be completely non-toxic. Even after years of use at therapeutic dosage levels, toxicity tests confirmed that this natural extract caused no toxicity, adverse reactions,
or unwanted side effects. Experts say this is because AHCC works to enhance the activities of the immune system, rather than attack cancer cells directly, as chemotherapy does. AHCC causes no side effects because
it stimulates the body's natural defense system to seek out and selectively destroy invading bacteria, viruses,
parasites, and cancer cells.
There are many immune stimulators on the market today, some backed by research documenting increases in NK
cell activity. But, only AHCC has shown the ability to actually promote cancer remission in human clinical trials.
WGP Beta Glucan (ImucellTM) Immune Support
What is WGP Beta Glucan (ImucellTM)?
Beta 1,3 glucan is a natural polysaccharide derived from Saccharomyces cereviseae, more commonly known as Baker's yeast. Whole Glucan Particles (WGP) Beta Glucan is the skeletal sphere that once provided structure to the yeast cell wall. This highly purified "cell wall ghost" binds with beta glucan receptors on the surface of macrophage cells, and other white blood cells that are the immune system's first line of defense. The beta glucan primes the macrophage and these other cells to defend the body from attack by identifying and destroying foreign invaders and communicating their presence to other immune cell defenders. This priming initiates a cascade of events leading to the expression of an overall heightened cellular innate immune response that includes increased:
1. Cellular mobilization, which is the ability to recognize "enemies" and move to the site of a foreign
challenge
2. Phagocytic capacity or the ability to engulf foreign and cancer cells. In one study, WGP Beta Glucan increased the killing efficiency of neutrophils 20- to 50-fold.1
3. Production of anti-microbial agent, such as reactive oxygen intermediates, that lead to an enhanced
ability of the immune system to defeat a challenge
WGP Beta Glucan (ImucellTM) and Cancer
Preclinical research has demonstrated potential of WGP Beta Glucan as a cancer treatment. Mice in a colon cancer model that were treated daily with oral WGP Beta Glucan for 21 days had a 21% decrease in tumor weight
and volume, compared with mice in the control group.1 The treated mice were found to have increased cytokine
levels IL-2 (2.3-fold), IFN-gamma (4.4-fold) and TNF-alpha (2.2-fold) over control animals.2
The researchers believe that WGP Beta Glucan stimulates the innate immune system cellular components (macrophages, neutrophils, and NK cells) to a higher functional level, increasing the first line of host defense mechanisms. This stimulation is mediated through specific interactions between WGP Beta Glucan and the Beta
1,3 Glucan receptors on the M-cells and macrophages within Peyer's patches in the intestinal mucosa in the gut associated lymphatic tissue (GALT) to stimulate a systemic protective cytokine signal.
A preclinical study using a breast tumor model illustrated the synergistic potential of WGP Beta Glucan with monoclonal antibodies. WGP Beta Glucan reduced tumor weight by nearly half. But when used in conjunction with a monoclonal antibody, the average tumor weight shrank by more than 80%.3
The use of WGP Beta Glucan is of special interest in the cancer patient undergoing chemotherapy and/or radiation treatment, writes Russell L. Blaylock, MD of the University of Mississippi Medical Center, since Beta Glucan have shown remarkable ability to accelerate hemotopeitic recovery in both sublethally and lethally irradiated mice, even when given after the radiation dose.4
Vitamin C Therapy
Cancer tissue liberates an enzyme called hyaluronidase, which dissolves hyaluronic acid (a protective agent of the connective tissue) and allows for the spread of tumors. This observation led two-time Nobel laureate Linus Pauling, Ph.D., of Palo Alto, California, to conclude that vitamin C would be of value in curing cancer based on the premise that more collagen fibrils (small, insoluble protein fibers that are often components of a cell) would
be formed, providing a more effective wall against the spread of the tumor. A controlled study provided startling evidence that megadoses of vitamin C increased survival time in cancer patients. Patients treated with vitamin
C lived an average of 300 days longer than patients who were not given supplemental amounts of the vitamin.
Perhaps the greatest evidence of the value of large doses of vitamin C in fighting cancer comes from the combined work of Abram Hoffer, M.D., Ph.D., of Victoria, British Columbia, and Dr. Pauling. In a recent study, forty patients with cancer of the breast, ovary, uterus, or cervix continuously received large daily doses of ascorbic acid and other vitamins. Another sixty-one patients with other kinds of cancer followed the same regimen, while thirty-one patients received no vitamin supplements and served as the control group. The control group lived an average
of 5.7 months. Of the others, 80 percent of the patients with cancer of the breast, ovary, cervix, or uterus had a mean survival time of 122 months; while forty-seven patients with the other kinds of cancer lived for an average
of seventy-two months. This study shows that the length of life for those using vitamin C was thirteen to twenty- one times longer than those who did not receive it.
Vitamin C for Maximum Biological Response
Vitamin C is involved in many biochemical reactions and processes: collagen formation,1,2,3,4 wound healing,1,5
inflammatory response,6 free radical protection,7 and perhaps most notably, immune response.8,9
A number of research studies describe the effect of vitamin C upon leukocytes,1 such as natural killer (NK) cells,10 neutrophils,8 and lymphocytes.8 Vitamin C has also been described as necessary for normal macrophage activity.
Antioxidant Support
Numerous articles and several reviews have been published on the role of antioxidants and diet and lifestyle modifications in cancer prevention. However, the potential roles of these factors in the management of human cancer have been largely ignored. Extensive in vitro studies and limited in vivo studies have revealed that individual antioxidants, such as vitamin A, vitamin E, vitamin C, and carotenoids induce cell differentiation and growth inhibition to various degrees in rodent and human cancer cells by complex mechanisms.
Furthermore, antioxidant vitamins, individually or in combination, enhance the growth-inhibitory effects of x- irradiation, chemotherapeutic agents, hyperthermia, and biological response modifiers on tumor cells, primarily in vitro. These vitamins, individually, also reduce the toxicity of several standard tumor therapeutic agents on normal cells. Low fat and high fiber diets can further enhance the efficacy of standard cancer therapeutic agents; the proposed mechanisms for these effects include the production of increased levels of butyric acid and binding of potential mutagens in the gastrointestinal tract by high fiber and reduced levels of growth-promoting agents, such
as prostaglandins, certain fatty acids, and estrogen by low fat. We propose, therefore, a working hypothesis that multiple antioxidant vitamin supplements, together with diet and lifestyle modifications, may improve the efficacy
of standard and experimental cancer therapies. 29
Bio-Guard® is a micellized antioxidant combination of beta carotene, vitamin A, vitamin E, vitamin C, and selenium. Bio-Guard affords maximum absorption of fat-soluble vitamins. These vitamins have been reduced to water-soluble micelles. A micelle is a very tiny particle of water-soluble fat. Micellized vitamins have been clinically demonstrated
to be the form most efficiently absorbed through the intestinal wall and into the cell.
Supplements to Enhance Immune/Antioxidant Status
- ImmPowerTM (AHCC®) - 2-6 capsules daily on empty stomach
For prevention, the recommended dose is one gram per day taken as one 500 mg capsule in the morning
and again at night. This dose will help increase NK cell activity and support immune system functioning
for good health and general well-being. For those with cancer, AIDS, or other life-threatening conditions, the research indicates a therapeutic dose of two capsules in the morning, two at mid-day and two in the evening, for a total of three grams per day, to jump start NK cell activity. After 3 weeks, the dose can be
reduced to one gram per day (one capsule in the morning and one at night), to maintain the increased NK
activity level. 30-37
- ImucellTM - 2-4 capsules daily on empty stomach
WGP Beta Glucan (Imucell) is a natural food product whose immune-enhancing properties have been the subject of years of research and hundreds of scientific studies. Derived from the cell walls of Baker's yeast (Saccharomyces cerevisiae), WGP Beta Glucan primes macrophages and other immune system cells to defend the body against a broad range of foreign challenges. 38-52
- Bio-Guard - 1 dropperful 3 times daily (can be mixed with UltraPotent-C).
- UltraPotent-C® Powder - 2 teaspoons in water or juice 3 times daily
Ultra Potent-C®: More than Just Ascorbic Acid
Ultra Potent-C is a unique combination of ascorbates, ascorbate metabolites, and precursors. Each
of the components included in Ultra Potent-C is designed to participate in vitamin C metabolism and enhance uptake and retention. Recently, investigators compared the effects of Ultra Potent-C to ascorbic acid in healthy, adult volunteers in a double-blind study.10 Both Ultra Potent-C and ascorbic
acid were shown to enhance NK cell cytotoxicity; however, the investigators reported an advantage of Ultra Potent-C over ascorbic acid, which included improved NK cell activity during the first four hours post-administration, a greater increase in plasma levels of ascorbic acid, and a greater increase in
peripheral blood leukocyte uptake of ascorbic acid-18% to 25% above the levels reported with simple
ascorbic acid.
Interestingly, the ascorbic acid group actually showed a 29% depression in NK cell cytotoxic activity during the first four hours after administration, while the Ultra Potent-C group maintained baseline activity during this same time period. The significance of this finding is that there is potential for the
suppression of NK cell activity to be prolonged if ascorbic acid is administered on a regular basis, (e.g. every four hours).
Enzyme Therapy
Pancreatic enzymes can help in the treatment of cancer in several ways. Enzymes help expose antigens on the
surface of cancer cells, so they can be recognized as foreign and destroyed by the immune system.
They also help destroy CIC's produced when cancerous cells shed their antigens into the circulation to avoid detection by the immune system. Pancreatic enzymes can stimulate Natural Killer Cells, T-Cells, and Tumor Necrosis Factor (anticancer agents), all toxic to cancer cells.
According to Dr. Solorzano, by removing the "sticky" coating found on tumor cells, enzymes reduce the risk of tumors adhering to other areas of the body (i.e., prevent metastasis). And pancreatic enzymes can enter cancer cells in their reproductive phase when they are not completely formed and more susceptible to destruction. Vitamin A increases these effects, as it releases enzymes contained in lysosomes (components of the intercellular digestive system), and is often given in combination with pancreatic enzymes. In Germany, pancreatic enzyme solutions (Wobenzym-N) have been injected directly into tumors, causing them to dissolve.24
- Azeo-PangenTM Extra Strength - 5 tablets 3 times daily AWAY FROM FOOD (30 min before or 120 min after).
Azeo-Pangen Extra Strength is a comprehensive raw pancreas enzyme complex.
-OR-
- Wobenzym-N - 15 tablets between meals 3 times daily for 30 days; then 10 tablets between meals 3
times daily.
Proteolytic Enzyme Complex
Protein Malnutrition in Cancer
Malnutrition is extremely common in patients with malignant disease. Although the etiologies are due to multiple
factors, the predominant factor is the imbalance between nutrient and energy intake and nutrient and energy
requirement. The evidence to date suggests that cachexia is related to the host's response to the presence of the tumor. Differing histologic types of cancer can cause varying degrees of anorexia.
Between 10 and 30% of hospitalized patients suffer from malnutrition. A disproportionately large number of these have a diagnosis of cancer. One study noted that 88% of hospitalized cancer patients had less than 80% of predicted creatinine/height ratios and 42% had decreased triceps skin-fold thickness. Using the criteria of the Prognostic Nutritional Index, a numeric construct weighted heavily for serum albumin levels, evidence has been presented documenting protein calorie malnutrition in 55% of cancer patients undergoing major operative procedures.
There is strong evidence suggesting that malnutrition associated with malignancy has substantial prognostic significance. One study which reviewed over 3,000 cancer patients found that patients without weight loss and significantly longer survival than did patients with weight loss.
Malnutrition is also a prognostic indicator of poor response to many medical and surgical procedures. In as many
as two thirds of cancer patients, death may be attributable to progressive tissue wasting. Although cachexia is almost universal in advanced malignancy and is common in gastrointestinal cancer, a consistent relationship does not exist between the development of cachexia and the stage of the disease, tumor histology, primary site, or duration of illness. It is clear, however, that cachexia is related to the presence of the malignancy. Animal studies have demonstrated that tumor implantation in rats lead to a rapid decrease in food intake and resultant weight loss: excision of the tumor leads to a rapid reversal of these trends. Successful anti-tumor therapy in humans often leads to improved appetite and sense of well-being, sometimes occurring before appreciation of objective response.
Although it appears that nutritional support in humans does not preferentially feed the tumor over the host, a definitive study on the impact of nutrition on tumor growth in humans is lacking. Nutritional repletion is usually given currently with radiation, surgery, and chemotherapy. Thus, a rationale for feeding cancer patients comes from an association of improved nutritional parameters with improved outcome of various forms of oncologic therapy.
Systemic Detoxification
Metabolic Detoxification Program
Detoxification programs deal with underlying toxicity issues in cancer itself and standard cancer therapies
utilized.
- Implement the appropriate detoxification program outlined in the Detoxificationsection of this guide.
Chemotherapy and/or Radiation Therapy Support
Nutritional Support for the Patient Going Through Chemo or Radiation Therapy
Chemotherapy works by trying to destroy fast-growing or replicating cells. Unlike most normal, healthy cells,
which grow slowly, cancer cells replicate very quickly, amassing into tumors and metastasizing (spreading) to other areas of the body. Chemotherapy is intended to poison and kill quickly replicating cells. Unfortunately, chemotherapy does not have the ability to discriminate rapidly replicating cancer cells from rapidly replicating normal, healthy cells, such as hair, nail, and stomach lining cells, which are killed off during chemotherapy. This explains why so many cancer patients endure hair loss and vomiting during chemotherapy
- ImmPower (AHCC®) helps fight the side effects of chemotherapy.
- Liv.52 - 6 to 9 daily prior to and during treatment; 2 to 4 post-treatment
Several research studies indicate an Ayurvedic liver formula, such as Liv.52, may protect against the hepatotoxicity of anticancer drugs, thus minimizing their side-effects and improving their efficacy.
Proactive and Protective Nutrient Recommendations for Cancer Patients
1. Plant nutrients counteract every phase of progression, Alkalize, Detox, Chelating Agents.
- Phyto Complete® - 10 tablets 4 times daily
Phyto Complete is a nutrient-rich superfood formula with whole food concentrates designed to provide
synergistic phytonutrient nutrition.
2. Antioxidant protection and enhanced cellular function
- Multigenics® Intensive Care Formula without Iron - 8 tablets daily
Multigenics Intensive Care Formula without Iron is a comprehensive multiple vitamin and mineral formula suitable for adolescents, adults, and seniors that provides an essential, comprehensive foundation for optimal health.
- Ultra Potent-C® Powder - 2 tsp. in water or juice 2 to 3 times daily
Ultra Potent-C Powder is an exclusive, patented formula that is designed to enhance the utilization of
Vitamin C. Preliminary scientific research suggests that vitamin C in the form of Ultra Potent-C may result
in improved uptake by white blood cells when compared to regular ascorbic acid.
3. Oils - Anti inflammatory, 7 proven anti-cancer mechanisms
- EPA-DHA High Concentrate LiquidTM - 1 teaspoon 4 times daily
High Concentrate EPA-DHA Liquid provides at least 2,800 mg per serving of EPA, DHA, and other purity- certified, omega-3 essential fatty acids in triglyceride form.
- GLA Forte® - 2 capsules 4 times daily
GLA Forte features borage seed oil, an essential fatty acid that is converted in the body to DGLA (dihomo- gamma-linolenic acid), the direct precursor of beneficial series 1 prostaglandins.
- Ultra CLA® - 2 softgels twice daily
Ultra CLA is a stabilized, mixed-isomer conjugated linoleic acid (CLA) formula in triglyceride rather than
free fatty acid form for enhanced stability and tolerance.
4. Medium Chain Triglycerides provide energy w/o insulin increase
- UltraClear PLUS® Medical Food - 2 scoops twice daily
Metabolic Detoxification for Imbalanced Detoxifiers
5. Trophoblastic Theory
- Azeo-PangenTM Extra Strength - 5 tablets 3 times daily AWAY FROM FOOD (30 min before or 120 min after).
Azeo-Pangen Extra Strength is a comprehensive raw pancreas enzyme complex
6. Protein - lean, clean and low inflammatory potential (enough to maintain BCM)
(antibodies) and Branch Chain Amino Acids which are anti-catabolic.7. Glutamine has 7 anti-cancer mechanisms
- Glutagenics® - 3 tsp. mixed with water 3 times daily
Glutagenics features three key ingredients-glutamine, deglycyrrhizinized licorice (DGL), and aloe vera-
that comprehensively support the integrity and healthy function of the gastrointestinal lining.
8. Detoxification of carcinogens and cancer toxins
- AdvaClear® - 2 capsules twice daily
AdvaClear provides unique support for balanced activity of the body's detoxification processes.
9. Immune Stimulation
- ImmPower (AHCC) - 2 capsules 3 times daily
- ImmPower is an extract of a unique hybridization of several medical mushrooms known for their immune
enhancing abilities.
- Imucell (WGP Beta Glucan) - 2 capsules 3 times daily
- Imucell primes macrophages and other immune system cells to defend the body against a broad range of foreign challenges.
Dietary Suggestions
References AHCC:
1. Kitade, H et al XXXIIIrd Cong. of Euro. Soc. for Surg. research, p 74, 1998.
2. Ghoneum, Mamdooh Ph.D. Society of Natural Immunity, pp 56, 1997.
3. Ghoneum, M.,et al. International Journal of Immunology, XI (1) pp23-28, 1995
References WGB Beta Glucan
1. Onderdonk, AB, Cisneros, RL, et al. Anti-infective of poly-B-1,6-glucotriosly-B 1,3-glucopyranose glucan in vivo. Infection and Immunity.
1992;60:1642-1647
2. Ross, GD, Vetvicka, V, Yan, J, Xia, Y, Vetvickova, J. Therapeutic intervention with complement and beta-glucan in cancer. Immunopharmacology.
1999 May;42(1-3):61-74 Review. PMID:10408367 [PubMed-indexed for MEDLINE]
3. Jun Yan, Vaclav Vetvicka, Yu Xia, Angela Coxon, Michael E. Carroll, Tanya N. Mayadas, and Gordon D. Ross. B-Glucan, a "Specific" Biologic Response Modifier That Uses Antibodies to Target Tumors for Cytoxic Recognition by Leukocyte Complement Raceprot Type (CD11b/CD18) J. Immunology 1999;163:3045-3052.
4. Blaylock, R. Yeast B 1,3-glucan and its uses against Anthrax infection and in the treatment of cancer. J American Nutraceutical Ass'n.
v5 n2, Spring 2002.
References Protein:
1. Bistrian BR, et al: Prevalence of malnutrition in general medical patients, JAMA, 235:1567 (1976).
2. Willcutts HD: Nutritional assessment of 1,000 surgical patients in an affluent suburban community hospital, J Parenter Enter Nutr, 1:25 (1977).
3. Nixon DW, et al: Protein calorie malnutrition in hospitalized cancer patients, Am J Med, 68:683 (1980). Buzby GP, et al: Prognostic nutritional index in gastrointestinal surgery, Am J Surg, 139:160 (1980).
4. DeWys WD, et al: Prognostic effect of weight loss prior to chemotherapy in cancer patients, Am J Med, 69:491 (1980).
5. Popp MB, et al: Prospective randomized study of adjuvant parenteral nutrition in treatment of advanced diffuse lymphoma, Surgery, 90:195 (1981).
6. Shamberger RC, et al: A prospective randomized study of adjuvant parenteral nutrition in the treatment of sarcomas, Surgery, 96:1 (1984).
7. Daly JM, et al: Parenteral nutrition in esophageal cancer patients, Ann Surg, 196:203 (1982).
8. Hickman DM, et al: Serum albumin and body weight as predictors of postoperative course in colorectal cancer, J Parenter Enter Nutr, 14 (1980).
- Warren S: The immediate causes of death in cancer, Amer J Med Sci, 184:610
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