Pancreatic Cancer

Complementary therapies, diet and other lifestyle changes

Complementary therapies
Many of the people we interviewed used complementary approaches, such as massage, relaxation and dietary changes, alongside conventional treatment. Complementary approaches to dealing with cancer have been less thoroughly tested than conventional medicines. They have no proven effect on cancer growth, but they seem to help many people to cope with feelings of stress, anxiety and depression, and make people feel better. Some may also help to reduce particular side effects. Relaxation techniques are now often part of conventional support for many patients and are increasingly being offered free at cancer treatment and support centres and at hospices, as part of a psychological approach to learning how to manage the stress of cancer. Sometimes people are invited to leave a donation; others pay for complementary therapies from private practitioners (also see ‘Other sources of support’).
A few people we interviewed said they would not consider using complementary therapies for their cancer: they trusted their doctors and only believed in treatments that had been tested scientifically. They felt cynical about expensive, unproven treatments offered on the internet or suggested by well-meaning friends or relatives. Others hadn’t considered complementary approaches.

Steve considered only ‘clinically proven’ treatments. He felt complementary therapies might be...

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Age at interview: 47
Sex: Male
Age at diagnosis: 47
Have you ever tried any, or thought about trying any complementary therapies?
No. Actually that’s something I will be quite clear about in my mind, I would only consider medication which is clinically proven, has been through tests and protocols etc etc. I would very much take the view that conventional medicine would be the right course for me. I think a lot of people get hooked up on all sorts of weird and wonderful things, which are at best unhelpful, at worst expensive, and possibly are even damaging. 
I feel quite sorry for people who search desperately for every possible alternative, crushed this, that and the other, or infusions of the other. No, I, that’s not for me at all.
Others were more open-minded about trying complementary therapies and found some had helped. Donna, for example, who had decided to have only palliative care, loved the reflexology she had in a hospice. Reflexology is a kind of foot or hand massage derived from Chinese acupressure. Pressure is applied to the feet and hands with specific thumb, finger and hand techniques; such work is supposed to effect a physical change in the body. It does not involve oils.

Reflexology made Donna feel very relaxed. She also tried aromatherapy but found the smell of the...

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Age at interview: 54
Sex: Female
Age at diagnosis: 53
What was it like when you stayed in the hospice to have your pain control?
I was bored. The hospice was lovely. They were very kind in there and, you know, they did all that they could to make me comfortable but, you know, it was a lot of elderly people in there and quite a few dying as well and it was just a boring environment for me and I couldn’t wait to get out of there. But the actual place itself was, is very nice, you know, the way it’s laid out. There are lots of nurses per patient. Far more than in a hospital, so medical, you know, drugs and things are available a lot quicker to you if you need them and they have more time to talk to you and that. And they’ve got various alternative therapies that they offer you such as reflexology, massage, aromatherapy and they do classes like pottery and bead making. So there are things that you can do but even so, the hours did drag.
Did you have any of those complementary therapies?
Yes, I did and I had few of them, especially reflexology, which I loved, which was foot massage. That was wonderful. It made me feel so relaxed.
Had you ever had it before?
No, it’s all new to me. It was very, very nice. It’s the only thing I miss, actually.
Did you have anything else?
Aromatherapy and I had just straight forward massage once.
Any good?
Not bad. I wasn’t keen on the aromatherapy because I found the smells a bit overpowering. The massage I liked but my favourite was definitely the reflexology.
Others found Reiki helpful. This is a Japanese system of ‘natural healing’. During Reiki the practitioner’s hands are gently placed in a sequence of positions over the whole body. No clothing is removed. Through the use of this technique, practitioners believe that they are transferring healing energy through the palms; some believe that healing can also take place at a distance. Michael said that having reiki before surgery made him confident that he would survive the operation, and during adjuvant treatment it helped him to cope with side effects.

When Theadora’s mother was having chemotherapy Reiki helped her cope with the side effects

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Age at interview: 64
Sex: Female
Age at diagnosis: 45
You said that sometimes she felt quite unwell after the chemotherapy?
Yes she did.
Can you remember what sort of problems she had as a result of it?
She was very, felt very sick. And she felt extremely tired, and very uncomfortable. Yes.
Did she take; did they give her medicines to help?
Yes, I don’t think anything though was, was really good enough. She found the Reiki very helpful.
Did she?
Which she found surprising because she thought it was a load of old tosh. But she nevertheless was open enough to say, “I think it’s all ridiculous,” but something about the relationship with the Reiki healer and the Reiki itself she found very useful.
Did she tell you what happened during a session of Reiki?
Yes, yes she did. She’d talk about a feeling of relaxation, warmth, peace, sometimes visualization, and yes she was very intrigued by it. 
For others who don’t know about it can you say a bit more about what happens?
Yes, she, it would be a session for about an hour. And she would go into a room. She would lie on a bed, table. And then the Reiki healer would hold her hand, it was a woman, would hold her hands, about eight, ten inches away from her body, and channel universal healing energy is what I believe they would describe it, to my mother.
And she’d feel her feet get very hot, and her hands would get very hot, and she found it a very positive experience, which she would never ever have done before she had cancer. But she was absolutely clear that anything was an opportunity. She would, she never hesitated for a moment that her focus was life.
Did she have to pay for that, or could she have it free?
No. It was a free cancer care support centre. And you could give a donation, which she did. And we gave a donation and we asked people to donate to that cancer centre when she died. But there, everything that was there was free.
Tai Chi is a Chinese martial art practised for both its defence training and its health benefits. John (Interview 40) found this type of body movement very relaxing.

Months after surgery, John did Tai Chi at a Maggie’s Cancer Caring Centre. He found it relaxing.

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Age at interview: 57
Sex: Male
Age at diagnosis: 52
Have you been in touch with any support groups?
Yes, initially, when I was diagnosed with pancreatic cancer I was told about Maggie’s Cancer Care Centre.
And although I was told I just didn’t bother but about six months after my operation my GP suggested that I visit them and I went there and that was really terrific for me, sitting talking with people with the same cancer, or similar cancers, and the experience they went through, and that really helped. And, unfortunately, a lot of people don’t know that places like Maggie’s Cancer Care Centre exists.
And they should be given more time and effort towards them to help people.
So how often do you go there, have you been there?
Well, I’ve not been for quite a while but I used to go every second day, every third day, when I was going for relaxation exercises.
Every Thursday.
No, no, every second day. It was just it was I think the Thursday, no, Tuesday and a Thursday I tell a lie, Tuesday and Thursday I went and they had relaxation courses, and they did some tai chi, which much to my surprise, was very, very helpful. It was very relaxing.
Tell me about tai chi?
Well, well, it’s a form of, well, combative dancing, as it were, and just it’s, it’s very relaxing. It’s just movements of the body and trying to relax at the same time but it was very worthwhile.
Do you do that with music?
Yes, we did it with music. They had music or they put a tape on, and they gave us a tape to take home with us if we wanted to try it at home.
But it was certainly, it was, it was very therapeutic when you were in the group.
Massage helped some people. William, for example, found that head massage helped to reduce his stress. He also had a body massage. Davinder found that gentle massage, a hot bath and balm ointment were sometimes just as good as painkillers.

Davinder believed in the power of self-healing. After her operation she learnt how to massage her...

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Age at interview: 65
Sex: Female
Age at diagnosis: 65
And I was very aware of, like I said many times this, that the body’s healing power is enormous, and the more you use it the more it helps you. And it’s endless, it’s more than, it’s stronger than any strong painkillers. This is how it reacts. You know, like I used, used the massage for myself as well.
Like when I had a back problem back in 1990, since then I started to do a massage on myself.
You can massage yourself?
Yes, on myself, this is when I started to believe in self-healing powers, so much body’s recovery from this. Like rather than going for painkiller, I will sit there peacefully, light a candle in the evening, have a dip in the bath, like sit in the bath for a couple of, 15, 20 minutes with the lavender oil and things, and come out and give yourself a massage as well, or probably before having a sit down in the bathtub. The massage, it helps. I do it all the time, like myself. Like if I got a pain up here, the tense neck, I will massage myself gently and it helps me. So this is my big thing, these two things, that body reacts to when you do help yourself and body tells you immediately. Rather than going for a painkiller, massage helps me for two painkillers like, honestly.
Because some complementary therapies may be inappropriate for people with particular types of cancer or having a particular treatment, people with cancer should discuss complementary therapies with their hospital specialist before having them. For instance, certain types of massage may be dangerous for patients with cancer. Some people worry that a massage may make the cancer cells travel to other parts of the body. No research has proved that this happens. However, there are reasons why it is important for people with cancer to consult their doctors before undergoing a deep massage, to see if it is advisable. Rory was on the TeloVac trial, which included vaccine injections and chemotherapy. She had regular foot massage, which she loved, but she felt very ill after having a full body massage.

Rory felt ill after aromatherapy with a full body massage. Her consultant told her this was not a...

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Age at interview: 66
Sex: Female
Age at diagnosis: 65
But the one thing that I did do and it was, I didn’t realise was I did actually have a massage. Nobody told me not to have a full body, body massage. I had a full body, body massage and was incredibly ill… the next day. And when I mentioned it to the consultant he said, “Oh no, you mustn’t do that.” 
Why? Why does that happen? Do you know?
No, I don’t. I’ve never heard of it.
 “Because you, you are on chemotherapy,” he said, “you shouldn’t have a full body massage.” 
Presumably it makes things whizz round you quicker, I don’t, I just don’t know. But I know I felt very, very ill the next day. I felt like a wet rag. I, I could hardly get out of bed. My limbs ached and I felt really quite poorly.
That’s interesting. 
Yes. So I had sort of quite a bad reaction.
Simon’s wife, Karen, discovered she had cancer in 2007. Before she died in 2009 she tried many complementary therapies, including Carctol (a mixture of eight Indian herbs), spiritual healing and the Bowen Technique. In a Bowen Technique session, the patient, wearing loosely fitting clothes, lies on a bed and relaxes. The therapist applies gentle rolling or flicking movements along the spine and at specific points on the body. These movements consist of a subtle rolling of muscle, nerve, tendon and connective tissue. The therapist leaves the room between each pattern in the series to give the patient time to relax and reflect.

Both Simon and his wife, Karen, visited a therapist who practised the Bowen technique. Simon...

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Age at interview: 39
Sex: Male
You know she was also seeing, seeing a therapist who was using the Bowen technique, and he was, he’s, you know he’s in that whole world of complementary health so he had some product that she was, that he was getting for her as well.
What is that? 
Bowen, I’ve had it done so I know. It’s actually quite powerful really. I don’t know quite what it’s based on, what actually happens is that you lie on, on the table and there are certain, it’s all based on probably, goes back to Chinese medicine maybe, there are, there are certain areas of the body, pressure points or whatever, that he sort of manipulates for a while. And then will just sort of touch a particular area and then stop. 
And, so I remember sort of chuckling to myself really thinking I’m paying money for this, and he was sort of you know would just lightly touch one area of your body. And then go off out of the room [laughs]. You know and go and make a cup of tea. And then come back and do it again. But I must say that it sort of seemed quite powerful.
Some people used visualisation to cope with pain. By conjuring up positive pictures, visualisation can change emotions that later have a positive effect on mind or body. Peter (Interview 36) practised visualisation when he was suffering the effects of chemotherapy. He visualised pleasurable situations, such as being with his son on the Thames (see 'Side effects of chemotherapy').
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David had reflexology at the hospice. He also learnt breathing exercises and visualised being in...

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Age at interview: 45
Sex: Male
Age at diagnosis: 38
Have you ever used any complementary therapies?
Yes, when I had the referral with the, with the Macmillan team it was discussed. One thing I used to enjoy, and did till recently, was I had massages. A lady used to come to the house, and my wife would have one too. 
But it, that apparently isn’t good for you, in that, in that it can, the massage can assist with, with spreading the illness. So as a result of their advice we didn’t do that, and what Macmillan did do, is talk about other alternative therapies that they do. And I’ve been to meet the, the team there, discussed what, what things they can do, and I’ve had some reflexology which I do find very comforting, very soothing, and it gives you a time out.
And again during those sessions, and I can’t believe it, big burly detective for 20 years, I did some breathing techniques, and some techniques to use if you can’t sleep or if you’re in pain. And they do work. And I thought, you know, this is like baloney, in one ear out the other ear, but a couple of occasions since, when I have had back pain, I’ve used that technique and it has assisted in reduce; especially breathing, the way that you breathe, not by taking deeper breaths, that you can reduce the pain a lot.
Who taught you that?
The lady who does the alternative therapies. Whilst we were doing the reflexology she would discuss with you, with the first session I did we discussed generally breathing, and breathing techniques to assist in pain. On the second occasion we introduced the technique where you kind of, enter a wood and walk through the wood, and go and find a house, and go to the house and you’re inside the house, as a way to take yourself out of a situation.
So it’s visualisation?
Yes. I don’t know what the technique is called, but yes. I visualise it, literally as a technique to sometimes take you to a more calming place and try and change your demeanour. Is demeanor the right word?
Does she come here for that?
No I go to the hospice centre.
Maureen also stressed the importance of treating mind, body and spirit at the same time. She imagined that she was throwing her cancer cells out of the window when she got up in the morning, and she told her body that her medicines were there to help her.
Richard (Interview 22) wanted to give up smoking, saw a hypnotherapist, and succeeded. The hypnotherapist suggested that Richard should also use hypnotherapy to heal himself and taught him how to hypnotise himself. Richard believed in conventional medical treatment but also that his mental attitude towards his illness mattered.

After hypnotherapy Richard often went to sleep and woke up as though he had had a sauna. He ‘felt...

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Age at interview: 59
Sex: Male
Age at diagnosis: 58
So I went to see a hypnotherapist, and explained what the problem was, and he said, that I have some, well it seemed quite logical which was that my rational mind had said, “You must give up smoking.” But my sub-conscious mind was saying, “Go on, it’s all right. You’ve always enjoyed it.” And that had been the one that had always won because actually one’s rational mind would have stopped me smoking years ago. 
And so he said, you know, “If I can work on your unconscious mind, I think we can then get you into equilibrium and you can relax.” So, we did that. And it turned out that I’m very susceptible and I can go into a trance just like that. And I was very happy doing that. And when we’d finished that session he said to me, “Have you considered using hypnotherapy as a means of cleansing your body, and of healing yourself?”
So I said, “No, I’ve never considered that.” So he said, “Well would you like to?” So I said, “Well, why not?” And he said, “Well I’ll tell you what, I’ll, I’ll do you a session half price.”
And so I went back about a week later. And he put me in a trance and I don’t know whether you’ve ever had any hypnotherapy, but one thing now that you do is that they record the, the process as it happens, and then burn it onto a CD so that you can go into the trance again whenever you want to reinforce your feelings. And so this particular trance which is all about healing, I have used on a number of occasions. And it’s very interesting, when I’ve, when I’ve done it I nearly always fall asleep and then I wake up and it’s as though I have been in a sauna. I’ve sweated out all the toxins in my body.
Which is, is fascinating. And he’s also taught me how to self hypnotise myself, so I can actually self hypnotise myself. Put myself in a trance, and in particular talk to my tumour about how unwelcome he is, and how strong I feel and how my body is capable of withstanding this. So that’s my one bit of alternative therapy…
And so it, I mean my attitude to the alternative therapies is very much to sort of have an open mind.
My, you know, my core thing is I do believe that you know the best way of treating my disease is via conventional medical therapy. On the other hand I’ve read a, I’ve had a very powerful belief that my mental attitude towards it is also critical. That my belief that I am capable of beating it is pretty important, because if I don’t believe that I’m capable of beating it who else can believe it? So that bit of sort of mental attitude has been very important to me. 
David’s (Interview 30) wife, Fiona, also had a couple of sessions of hypnotherapy to put her mind ‘in the right orientation’ but David said she didn’t find it ‘hugely helpful’.
Some people question the idea that positive thinking is important for the healing process. Ann, for example, said that this notion wasn’t right for her. She wondered how she would feel if she ‘wished her cancer away’ yet remained ill.
Dietary and other lifestyle changes
Many people we interviewed had changed their diet because the cancer (or the treatment) had affected their digestion (see ‘Long term effects of the cancer and its treatment’). Others changed their diet because they thought a different diet might help to cure their cancer. Some reduced their consumption of meat, dairy products, smoked foods or alcohol (also see ‘Everyday life and facing the future’). Others cut out some acidic foods or ate more alkaline foods. Although research shows that eating a healthy diet can reduce the risk of developing certain types of cancer, so far no scientific evidence indicates that following any particular diet, or cutting out key elements of a normal diet, as some therapists advise, can treat cancer or prevent it coming back.

David’s wife, Fiona, tried various complementary therapies. She changed her diet and used...

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Age at interview: 43
Sex: Male
In terms of food and things, we also looked at nutritional things. There seems to be a very big literature out there which talks about good foods, bad foods, in terms of cancers. So, we followed those which seemed to be, we, we didn’t just follow one person saying you’ve got to do this, we kind of looked at it …
… And there seems to be families of foods which are good. So, things like fruits which, the redder, the darker, red fruits all seemed to come up scoring quite highly, so we went for that. I was open-minded, and I think that Fiona was open-minded but quite kind of, quite determined to follow through on the good things. So, probably a slightly greater lead from Fiona than myself, we never really sat down and said, “What do we think really works here?” We, it, it kind of just all morphed into a way of, of being and I think we just felt that we’ll tackle this whichever way we can. And we were fairly open-minded. So we had the kind of nutrition, foody things that we were doing. Things like fried food was off the agenda. 
Then you’re moving into kind of the, the vitamins and minerals and the food supplements of which there is a big literature. So we looked at those things and we managed to end up with quite a few containers of capsules and the like. And we were quite open to our GPs, the other medical people, it’s like we told them, “Look, we’re open-minded to this”. I think probably we asked them, “What’s you view?” I think their view was, they were slightly open, well fairly open-minded and that they wouldn’t be able to tell us, yes/no on these things. And that goes with the specialist care at the hospital where we received the more traditional kind of stuff. I think our worry was that you’d get conflicts and people saying …
 “Whatever you do, don’t do that”. Or, “If you do that you’re going to worsen this.” We didn’t get that.
Which I think was good. 
Theadora’s mother adapted her diet based on ideas from a book by Michael Gerson and the dietary approach advocated by what was then called The Bristol Cancer Help Centre, now renamed the Penny Brohn Cancer Care. This charity offers complementary therapies, advice & counselling for people living with cancer and their supporters.

Theadora’s mother changed her diet and almost became vegan. She felt confident that that improved...

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Age at interview: 64
Sex: Female
Age at diagnosis: 45
She did a lot of exploration about diet. She was very interested in the Bristol Cancer Centre [now renamed Penny Brohn Cancer Care] method, and she read about that. And she looked for people who were interested in the Bristol Cancer approach in the area that she lived in. And so she went to see somebody, to talk about that. And she changed her diet radically, radically, radically. She talked to, she read the Michael Gerson book about living with cancer and your diet. And she changed her diet so she became very vegan virtually. Lots and lots of fresh fruit and vegetables, and she became very interested in the issue about alkali and acid. And so she ate, she ate a broadly alkaline diet. It became extremely complicated, but we did what she wanted to do…
She for example drank fresh carrot juice three times a day. She cut out all dairy. She cut out all meat. She cut out caffeine,, and she cut out citrus fruits. She aimed to make her body alkali rather than acid. All one can say is that the prognosis, because whilst she wasn’t interested, I was interested, and we would talk to the doctors, and the doctors reckoned she had six months post diagnosis. She lived two and a half years.
So who knows? Diagnosis and prediction is a very particular art form, and the interaction with the patient is really important. So she, she was very clear and she was, she felt confident that what she was doing was making a difference. And certainly her mental attitude which was about control, doing what she could do, was important.
Some people took extra vitamins or minerals or other ‘health products’. For example, Maureen took flax oil and Simon’s wife, Karen, took a mixture of eight Indian herbs called Carctol. Although some doctors in the UK use and prescribe Carctol for people with cancer, Carctol isn’t a licensed medicine in the UK because there isn’t enough evidence to prove that it is safe or works as a treatment for any type of illness.

When Simon’s wife was very ill she spent a lot of money on various products, including vitamins,...

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Age at interview: 39
Sex: Male
Yes. It was, I did you know mentally decide to join her on the quest. So I didn’t allow myself to think negatively. Even when I saw the data, because it all boiled down to a similar picture really of life span, life, you know expectancy etcetera, given what she had. But I also then, you know, focused on any glimmer of hope. And that’s when you do; I did stray from the academic papers in looking for more anecdotal evidence of things can work. And Karen was also doing some research as well in terms of, well I bought her a book by a woman who Karen sort of had heard about. And you know I don’t, I’m very, I feel very cynical about this particular woman and what she does. And she’s just one of a whole host of people. As I say there’s an industry out there that that is built on people who are dying. 
Was she offering complementary therapies?
Yes. Yes..
What sort of therapy?
Well she, I mean she in particular, what she, what she got you to buy was, her kit, the lifeline kit, which involved a, you know a folder and various leaflets and pamphlets as to the things to do, but also vitamins and various health products that you had to buy through her. 
And did you buy those?
Yes, Karen absolutely, you know and you know I backed her everything, everything she wanted to do I backed you know.
So she took extra vitamins and things?
Yes. And actually I do think that they probably worked. You know she absolutely you know went to town on healthy products and I, again when you look at how gobsmacked the specialists were, at how well she was, way into her treatment, there had to be something that was causing that. And I think her attitude and probably the things that she was taking were helping. But some of the products that were, that she was told that she should take I think were so you know, what was it, Carctol I think, some Indian plant extract, extract that she was on, that she was told to take you know. And you have to take enormous quantities of these things.
Did she take, did she take it?
Yes, yes, yes. And you know on one hand people are offering these things, yes taking healthy products and vitamins is, is always going to be a good idea. And she subscribed to Karen’s optimism and enthusiasm which mentally for Karen was brilliant you know.
Yes, she tried a whole host of things. I mean there were, there were, there were vegetable extracts, there were you know fruit extracts, there were a whole host of pills. I mean she, she, she spent hundreds, probably thousands of pounds on products,
You know and she would take them religiously every day. And I do think they worked. I think if you, if you bombard your body with you know with all these intense forms of vitamin etc, and mineral, you know it probably can’t be a bad thing really. 
As the word 'complementary' suggests, health professionals recommend that these approaches should be considered an addition to and not a substitute for conventional medical treatment. However, sometimes people choose to use therapies or dietary supplements as an alternative to conventional treatment. This may happen when people are told that there is no more 'active' conventional treatment, or when they feel that they've had enough of the side effects of conventional treatment. One of the men we interviewed decided not to continue with chemotherapy after seven cycles and took dried apricot seeds (kernels) instead. He reasoned that at this stage he had 'nothing to lose'. He went on to take an extract of apricot seeds in pill form instead called ‘vitamin B17’, which is not a true vitamin and its sale has since been banned in the USA and Europe. In spite of a warning from his doctor that these products contain cyanide and were therefore poisonous, he was convinced that they were doing him some good. There is currently no evidence to show that apricot seeds or ‘vitamin’ B17 work but randomised controlled trials have not been carried out.

He wanted no more chemotherapy to treat his pancreatic cancer and explained why he took dried...

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Age at interview: 72
Sex: Male
Age at diagnosis: 70
Can you tell me a bit more about why you’re so convinced these [apricot seeds] are doing the job for you as it were? Some people might say well it, it might have happened anyway.
Oh sure yes, well because after the seventh chemotherapy I went to see the specialist, the cancer specialist and she said, well, they scanned me then, and they said, “Well your tumour’s no smaller and it’s no bigger so it looks as though we can control it and I suggest you have another course” and I said you know, that’s when I made up my mind I didn’t want another course. I didn’t want to do it so she said, “Well you know come and see me again in three months” and every time I’ve been since she just says, “Well let well alone” and now she doesn’t want to see me for six months this time and my doctor was pretty much the same I mean she said, “You know those things you’re taking are poisonous don’t you” so I said “I know they are but so is chemotherapy” and she said, “Well you must be doing something right because you’re still here”.
The origin of the theory is that there is a tribe in the upper west Pakistan near the Himalayas called the Hunsa people, a small tribe of people and their, one of their main diets is apricots because they grow them there and they’ve always eaten the seeds as well and they’ve, there’s no cancer there, they’ve never had cancer and they live to considerable ages in spite of the fact that they live in a very harsh climate, and that’s where the idea comes from and the chemical side of it, again I don’t know, I’d have to refer to a book to tell you in detail, is that half of the, or part of the ingredient in the tablet, in the seed, apricot seed, is cyanide, it’s that and something else but the cyanide only splits if it meets cancer cells, if it meets a cancer cell it attacks it in your system in your blood stream, that’s the theory, very, very basically.

Some people said that well-meaning friends or relatives had suggested special diets or certain supplements but they had not followed their recommendations. Since his cancer diagnosis Tony has cut down the number of cigarettes he smoked from 20 to 3 or 4 a day.  

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Last reviewed September 2018.

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