Adjunct Ayurvedic treatment providing more than 10 years of disease-free survival in a rare case of male breast cancer patient with high-grade invasive ductal cell carcinoma - A Case Report

Abstract

Introduction

Male breast cancer (MBC) is an uncommon malignancy. In spite of conventional Allopathic treatment, long-term disease-free survival (DFS) of more than 10 years in MBC is rare, due to its aggressive nature.

Case presentation

We report a case of 56 years old, stage IIB and grade III invasive ductal cell carcinoma MBC (Lt) patient, operated for left modified radical mastectomy with axillary clearance followed by six cycles of chemotherapy during October 2010–January 2011. Patient was on hormonal treatment from March 2011 till May 2021. He opted for adjunct Ayurvedic treatment throughout the conventional treatments for the period of 10 years. Ayurvedic treatment in the form of treatment for pacifying imbalanced humors (Doshas) and disease (Shamana chikitsa) and treatment for immunomodulation (Rasayana Chikitsa); and periodic detoxifying treatment (Panchakarma Chikitsa) was given in this patient. He was also advised healthy diet and lifestyle at our center. The treatment chosen was mainly to reduce side effects of chemotherapy like anorexia, nausea, vomiting, constipation, diarrhoea, taste disturbance, mucositis, fatigue and fever. It also helped in improving quality of life and increasing DFS.

Conclusion

The long DFS of 10 years and 3 months with good Quality of Life and minimal side effects of conventional cancer therapy could be ascribed to the adjunct Ayurvedic treatment given to this patient. We have to observe the benefits in more number of patients in future to define usefulness of this treatment modality.

1. Introduction

Breast cancer is a common malignancy among females but Male Breast Cancer (MBC) is rare with statistics of only 1 % of all cancer-diagnosed patients [1]. In the last 25 years, there has been significant progress in the local and systemic management of female breast cancer (FBC). Still, it is unclear whether these advances have been applied to the management of MBC due to its rarity, prospective clinical trials specifically focused on MBC have not been conducted [2]. MBC patients had a worse overall prognosis than FBC counterparts which was in line with several previous studies reporting that FBC patients had a significantly longer Overall Survival (OS) than MBC patients. The median OS for MBC patients was 7.0 years compared with 9.8 years for FBC patients (log-rank test; p < 0.05) [3].

We present here a rare case of stage IIB, grade III ductal cell carcinoma MBC (Lt.), treated with adjunct Ayurvedic treatment at our center post-surgery, from the beginning of chemotherapy and before starting hormonal treatment. Ayurvedic understanding of the disease with respect to dimensions (Akruti), texture (Swaroop), colour (Varna), smell (Gandh) etc. of the tumour according to gross description of histopathology report is added in the manuscript. Accordingly, we have diagnosed the disease as Vama Stana Dushta Mansarbud with Vama Kaksha Dushta Granthi. Ayurvedic intervention and life style modifications were suggested to the patient considering Ayurvedic diagnosis. Ayurvedic treatment consisted of combination of Oral Ayurvedic Medicines (OAM) in the form of treatment for pacifying imbalanced humors (doshas) and disease (Shamana chikitsa) and treatment for immunomodulation (Rasayana Chikitsa); and periodic detoxifying treatment (Panchakarma Chikitsa). Shamana Chikitsa was mainly to minimize short- and long-term side effects of chemotherapy by improving appetite and digestion, reducing generalized toxicity and imparting anti-inflammatory effects, whereas Rasayana chikitsa additionally exerted immunomodulatory effects and improved quality of life of the patient. He was also advised to avoid unhealthy food and improper lifestyle. Patient has Disease Free Survival (DFS) of 10 years and 3 months with good quality of life.

2. Patient information

A 56 years old male patient was diagnosed with carcinoma of left breast in July 2010. Five years before cancer diagnosis, he had multiple injuries on chest wall and back; and had fractured left hand. He had heredity of cancer, paternal uncle suffering from hepatocellular carcinoma. He also suffered from multiple addictions like tobacco, masheri (a pyrolyzed tobacco product), gutakha (chewable tobacco form), cigarette smoking and alcohol.

In 2007 the patient discovered a peanut sized, painless nodule above his left nipple. By 2010 two more nodules appeared on left breast which developed into a big palpable mass on left chest wall with prickling pain. Fine Needle Aspiration Cytology of the mass showed neoplastic ductal epithelial cells (Supplement 1).

In July 2010 he was operated for left radical mastectomy with split thickness skin grafting and left axillary clearance at another hospital (Supplement 2). Surgical histopathology report confirmed infiltrating duct carcinoma (IDC), grade III (Supplement 3). This report established stage IIB disease of the patient as per American Joint Committee on Cancer (AJCC) guidelines.

The patient was then referred to our centre for chemotherapy and adjunct Ayurvedic treatment. He was treated with six cycles of chemotherapy (Inj. Cyclophosphamide 800 mg, Inj. Methotrexate 50 mg and Inj. 5 FU 500 mg), with periodicity of 3 weeks from October 2010 to January 2011. He was started with hormonal treatment with daily dose of Tab Tamoxifen 20 mg after completion of chemotherapy and continued for 10 years till May 2021. OAM was given to minimize adverse effects of chemotherapy and hormonal treatment. He continued OAM along with Panchakarma till May 2021 (and continued further) for disease control. He was doing well and was asymptomatic till February 2015. In Feb 2015 he developed severe backache. Bone scan in March 2015 revealed increased tracer uptake in L5 vertebral region (Supplement 4). He was treated with only Ayurvedic regime accordingly instead of local palliative radiotherapy, after consultation with Radiation Oncologist.

3. Timeline for health events and treatment

The timeline is depicted in Fig. 1.

Fig. 1.

Timeline of events in the reported male breast cancer patient

4. Diagnostic assessment

Chemotherapy induced short - and long - term side-effects such as nausea, vomiting, loss of appetite, taste alteration, fatigue, weight loss etc. were assessed before, during, end and one year after chemotherapy using CTCAE 4.03 Version [4]. Yearly radiological investigations like Mammography/PET CT was advised along with routine biochemistry and tumour markers like CA 15.3. Karnofsky Performance Score [5] and Quality of Life were assessed yearly, based on QLQ C30 and QLQ BR23 of European Organization for Research and Treatment of Cancer (EORTC) [6]. Ayurvedic parameters i.e. Ashtavidha Pariksha, Bala, Nidra, and Kshudha were assessed at various time points. The major diagnostic challenge in men is, they are often diagnosed with breast cancer at a more advanced stage as routine screening with Mammography is not done in them like females. In our patient, in view of financial difficulties, yearly PET CT scan was not done by him. Routine yearly biochemistry, tumour markers and radiological investigations like X-ray chest were done as mentioned in Table 1.

Table 1.

Details of assessment parameters with respect to time points of treatment.

Time points→	A	B	C	D	E	F	G	H	I	J	K	L	M	N
Status→	Before starting OAM along with chemotherapy	Mid chemotherapy	End of chemotherapy	1 y of OAM	2 y of OAM	3 y of OAM	4 y of OAM	5 y of OAM	6 y of OAM	7 y of OAM	8 y of OAM	9 y of OAM	10 y of OAM	May-21
Dates/Year →	01-09-2010	22-11-2010	28-01-2011	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021
Assessment parameters ↓
Anorexia	0	1	0	0	0	0	0	0	0	0	0	0	0	0
Nausea	0	1	0	0	0	0	0	0	0	0	0	0	0	0
Vomiting	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Constipation	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Diarrhoea	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Taste disturbance	0	1	0	0	0	0	0	0	0	0	0	0	0	0
Mucositis	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Fatigue	1	2	1	0	0	0	0	0	0	0	0	0	0	0
Fever	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Nadi	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta	Vatapradhan Pitta
Mala	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak
Mutra	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak
Jivha	Sama	Sama	Alpasama	Nirama	Nirama	Nirama	Nirama	Nirama	Nirama	Nirama	Nirama	Nirama	Nirama	Nirama
Shabda	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut
Sparsha	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut
Druk	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut
Akruti	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam	Madhyam
Bala	Uttam	Uttam	Uttam	Uttam	Uttam	Uttam	Uttam	Uttam	Uttam	Uttam	Uttam	Uttam	Uttam	Uttam
Nidra	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak	Samyak
Kshudha	Agnimandya	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut	Prakrut
Karnofsky Score	70	60	60	90	90	90	90	80	90	100	100	100	100	100
Functional Score of QLQ C30	78	78	80	89	87	84	91	93	93	96	98	100	100	100
Symptom Score of QLQ C30	10	31	18	5	5	5	8	10	5	5	3	3	3	0
Global Score of QLQ C30	83	67	75	75	83	83	83	83	83	83	83	92	92	100
Breast Score from QLQ BR 23	23	25	24	24	23	24	23	22	21	22	22	22	21	20
Hba(12–16 g/dl)	14.4	13.3	13.8	13.5	12.9	12.1	12.1	12	13.6	13.5	13.2	13.3	12.8	13.5
WBCa(4000–11000/cmm)	9900	4500	4500	7800	8700	8100	8200	9700	10500	11300	7700	8600	8000	8300
Plateleta(150000–450000/cmm)	346000	271000	406000	267000	286000	307000	326000	357000	380000	324000	285000	327000	347000	280000
S. Bil.a(0–1.2 mg/dl)	0.5	–	0.8	0.41	0.67	0.64	0.6	0.65	0.61	0.55	0.55	0.4	0.48	0.45
SGOTa(0–31 U/L)	18	–	22.7	41	36	20.34	25.1	20.61	23.56	22.04	16.77	23.88	27.64	16.47
SGPTa(0–32 U/L)	84.4	–	16.9	38	15	9	18	11.19	22.76	16.77	15.34	13.5	18.29	15.34
S Alk. Phos.a(44–147 U/L)	273.2	–	227.3	133	121	206	250	156.3	101.9	86.47	77.04	82.87	102.1	111.8
S. Creat.a(0.7–1.7 mg/dl)	–	–	–	–	1.3	0.7	1.2	1.1	1.29	1.1	1.39	1.28	1.34	1.26
S. Ureaa(13–43 mg/dl)	–	–	–	–	23.51	15.08	24.2	14.63	20.98	19.4	13	19.21	14.35	23.3
(Tumour marker) CA 15.3a(0–32 U/ml)	6.5	6.5	5.82	24	21	2.7	10	12.37	4.59	6.3	14.6	10	4.9	8.16
CRPa(0–6 mg/L)	–	–	–	–	–	–	–	–	1.37	1.64	0.65	1.2	1.3	1.38
Bone Scan								Mar 17, 2015 – Increased uptake in L5 vertebral region, further radiological correlation for L5 vertebral region can be considered.
PET CT														May 06, 2021- Operated for carcinoma of left breast (2010), post chemotherapy status, study shows no FDG avid locoregional recurrence or distant organ involvement.
X-ray Chest				Apr 28, 2011 – Normal radiological findings	May 25, 2012 – Small opacity about left supraclavicular region. Lung parenchymal appears normal.	Mar 13, 2013 - Normal radiological findings		May 06, 2015 - Normal radiological findings			Feb 14, 2018 - Normal radiological findings	Apr 04, 2019 - Normal radiological findings
USG Abdomen/Pelvis								Mar 16, 2015 – No focal lesion is seen in liver; no significant abnormality is seen in rest of the abdomen		Jan 09, 2017 – The urinary bladder is well distended with mild wall thickening. No calculi. Normal liver		Mar 27, 2019 – Fatty liver grade I, Rest study is within normal limits.		May 11, 2021 – Fatty liver grade I.

^aIndicates normal range of haematological and biochemical parameters.

5. Ayurvedic treatment and assessment

Ayurvedic physicians from our center carefully selected OAM consisting of combination of Shamana chikitsa and Rasayana Chikitsa. During chemotherapy and thereafter, medicines given were Kamdudha Vati (Mouktikyukta) (MKV) [7,8] and Atharva Praval Pishti Vati (APPV) [9,10], 250 mg each along with Atharva Shatavari Kalpa (ASK) [11,12], 5 g with cow's milk after breakfast and evening snacks and Atharva Ananta Kalpa (AAK) [11,13], 5 g with water after meals for a period of one year to minimize the short – and long – term side-effects of chemotherapy. Whereas for the next nine years he was treated with Chandraprabha Vati (CPV) [14,15] and Atharva Praval Pishti Vati (APPV) [9,10], 250 mg each with cow's milk after breakfast and evening snacks; Arogyavardhini Vati (AV) [14,16,17] and Triphala Guggul (TG) [14,18,19], in a dose of 500 mg each twice a day after lunch and dinner with lukewarm water in order to prevent recurrence/metastasis and to maintain good quality of life leading to DFS. OAM were given for the complete period of 10 years. Details are given in Table 2.

Table 2.

Details and mode of action of Shaman, Rasayan Chikitsa and Panchakarma Chikitsa.

Name of the medicine	Contents	Properties as per Ayurvedic texts	Mode of action in this patient	Action indicated in previous publications
Mouktikyukta Kamdudha Vati (MKV) [7]	1.Incinerated coral (Praval Bhasma) 2.Incinerated oyster shell (Shouktik Bhasma) 3.Incinerated cowry (Kapardika Bhasma) 4.Incinerated conch (Shankh Bhasma) 5.Incinerated pearl (Mouktik Bhasma) 6.Starch preparation Tinospora cordifolia (Guduchi satva) 7.Purified hematite (Shuddha Suvarna Gairik)	Excellent alleviation of Pitta Dosha (Pitta Shamak) Cold in potency (Sheeta), Reduces heat and burning sensation in the body (Dahashamak) Improves quality and quantity of blood component (Raktaprasadak) Coagulant activity (Raktastambhak) Improves digestion (Pachak)	MKV was useful in reducing side effects of chemotherapy as chemotherapeutic drugs are known to produce toxic effects in blood, produce inflammation, increase heat in the body and hamper digestion	Gastro-protective with anti-ulcer activity [8]
Praval Pishti Vati (APPV) [9]	Coral powder triturated with lemon juice and rose water	Antacid (Amlapittanashak) Cold in potency (Sheeta), Digestive stimulant (Agnideepan) Anti-arthritic (Sandhigata Vata Nashak) Anti-pyretic (Jwaranashak) Helps in bone healing (Asthisandhanakar)	It reduces inflammation and heat in the body and lowers the elevated body temperature with its intrinsic cold nature (Sheeta Veerya). Therefore, it was found to be useful in alleviating chemotherapy induced side effects like burning sensation, hot flushes, fever, etc. Due to its bone healing properties, it was used in this patient throughout the treatment period. This was to prevent metastasis in bones as he was detected with increased tracer uptake in L5 vertebrae in bone scan during the treatment period.	Regulation of Ca2+ signalling [10].
Atharva Shatavari Kalpa [11]	Sugar based granules of Asparagus racemosus	Akin to immunomodulatory effect (Rasayan)	It improved and maintained strength in the patient during chemotherapy and imparted immunomodulatory effect.	Anti-cancer activity in various cell lines including breast cell line [12]
		Anti-inflammatory effect (Raktajit)
		Improves appetite (Agnipushtida)
Atharva Ananta Kalpa [11]	Sugar based granules of Decalepis hamiltonii	Detoxifying (Vishaghna), Anti-pyretic (Jwaraghna) Anti-inflammatory effect (Raktadosha nashak) Improves appetite (Agnimandya nashak)	These activities of Ananta were beneficial to alleviate side-effects of chemotherapy and hormonal treatment and detoxify body leading to restriction in cancer progression.	Antioxidant and hepato-protective activity [13]
Chandraprabha Vati [14]	1. Cinnamomum Camphora (Bhimseni Kapoor) 2.Emblica officinalis (Amalaki) 3.Terminalia bellirica (Bibhitaki) 4.Terminalia chebula (Haritaki) 5.Piper longum (Pippali) 6.Piper nigrum (Maricha) 7.Zingiber officinale (Sunthi) 8.Curcuma longa (Haridra, 9.Cyperus rotundus (Musta) 10.Cedrus deodara (Devadaru) 11.Commiphora mukul (Guggulu) 12.Black bitumen (Shilajatu) 13.Incinerated copper pyrite (Swarna Makshika Basma) 14.Incinerated iron (Loha Bhasma), etc.	Anti-neoplastic activity (Granthi – Arbuda Nashak) scrapping and eliminating deep seated toxins (Acts on Dushta Mansa Dhatu with its Lekhana Karma)	This was administered to the patient as a drug of choice in treatment of breast cancer which is essential in preventing recurrence of cancer in breast tissues.	Anticancer, antioxidant and immunomodulatory properties of ingredients of Chandraprabha Vati [15]
Arogyavardhini Vati [14]	1.Black sulphide of mercury (Kajjali) 2.Incinerated iron (Loha Bhasma) 3.Incinerated mica (Abhrak Bhasma) 4.Incinerated copper (Tamra Bhasma) 5.Emblica officinalis (Amalaki) 6.Terminalia bellirica (Bibhitaki) 7.Terminalia chebula (Haritaki) 8.Pumbago zeylanica (Chitrakmool) 9.Picrorhiza kurroa (Kutaki) 10.Black bitumen (Shudha Shilajeet) 11.Commiphora mukul (Shudha Guggul) 12.Azadirachta indica (Kadunimbapatra)	Improves appetite (Deepani) Improves digestion (Pachani) Eliminating accumulated gross and minute waste product formed in the process of digestion at macro and micro level, thus detoxifying the body (Malashuddhikari)	Administration for a longer duration helped in preventing recurrence by detoxifying body and mainly liver with its' Malashuddhikara effect.	∗Hepatoprotective activity of Arogyavardhini Vati [16] ∗Anti-oxidant and anti-neoplastic activities of Kutki (Picrorhiza kurroa) extract, main ingredient of Arogyavardhini in various cancer cell lines including breast cell line [17]
Triphala Guggul [14]	1.Piper longum (Pippali) 2.Commiphora mukul (Guggulu) 3.Terminalia chebula (Haritaki) 4.Terminalia bellirica (Bibhitaki) 5.Emblicaofficinalis (Amalaki)	Beneficial in various inflammations and tumours (Shotha nashak)	A well-recognized and highly efficacious poly-herbal Ayurvedic medicine, was administered to this patient for longer duration as a drug of choice in breast cancer.	Anti-cancer activity of Triphala in breast cancer cell lines and animal models through anti-oxidant activity [18] Anti-inflammatory, anti-oxidant and anti-proliferative activity of Guggulu in various cancer cell lines including breast cell line [19].

Details regarding mode of action of Panchakarma treatment
Type of Panchakarma treatment	Contents	Action as per Ayurvedic texts	Mode of action in this patient	Action indicated in previous publications
Krumighna Basti [20]	Matra: 1.Azadirachta indica oil (Nimba tail) 10 ml 2.Vitex negundo oil (Nirgundi tail) 10 ml 3.Pongamia pinnata oil (Karanja tail) 10 ml Anuvasan: 1.Azadirachta indica oil (Nimba tail) 20 ml 2.Vitex negundo oil (Nirgundi tail) 20 ml 3.Pongamia pinnata oil (Karanja tail) 20 ml Niruha: 450 ml decoction of 1.Emblia ribes powder (Vidanga) – 10 g 2.Triphala (as given above) – 10 g 3.Moringa oleifera powder (Shigru) – 05 g 4.Cyperus rotundus powder (Musta) – 10 g 5.Baliospermum montamum powder (Dantimoola) – 10 g 6.Hordeum vulgare powder (Yava) – 10 g 7.Azadirachta indica oil (Nimba tail) 20 ml 8.Vitex negundo oil (Nirgundi tail) 20 ml 9.Pongamia pinnata oil (Karanja tail) 20 ml 10.Honey (Madhu) 30 ml 11.Rock salt (Saindhav) 10 g	Basti is recommended to control growth of cancer which is under the control of Vata Dosha. Basti is a treatment of choice of Vata Dosha, which is responsible for cell division. Vata Dosha in equilibrium state controls normal cell division, whereas in vitiated state causes abnormal cell division. Vata Dosha governs functions of remaining Doshas, Dhatus, Srotasas and organs. Dushta Arbuda, a condition akin to cancer is a Tridoshaja Vyadhi i.e., caused by vitiation of Vata, Pitta and Kapha Dosha. Therefore, Basti Chikitsa is beneficial to control growth of Dushta Arbuda and prevent recurrence and metastasis in cancer.	Drugs administered through Basti reach to all Roga Marga or body tissues quickly and shows their therapeutic effect in minimum time span. Recurrence of disease and/or metastasis occurs due to Dhatugata Dushta Dosha/Aama or accumulated toxins in the body. Basti Chikitsa helped to detoxify body through elimination of deep-seated accumulated toxins.	Significant improvement in the Quality of Life in patients of various types of cancers treated with yearly Panchakarma treatment [21]. Efficacy of Krmighna Basti in preventing recurrence/metastasis and improving quality of life is established in breast and gynaecological cancers (ovarian, uterine, vaginal and cervical) [22]. Besides Quality of Life, we have also observed increase in survival rate, reduction in inflammatory serum cytokines and ROS generation in erythrocytes extracts in breast and oral cavity cancer patients treated with Panchakarma (Unpublished Work). Basti Chikitsa modulates immune responses by regulating pro-inflammatory cytokines, immunoglobulin and functional properties of T-cells [23]. Phytochemicals of the Basti formulation are absorbed in systemic circulation [24].
Vaman [20]	1.Randia dumetorum (Madanphala) hot infusion 100 ml 2.Glycyrrhiza glabra (Yashtimadhu) decoction QS 3.Rocksalt (Saindhava jala QS)	Vamana is indicated for cleansing/detoxifying Rasa Dhatu (Rasa Dhatu Shuddhi and cleansing of organ – breast (Aashaya Shuddhi). Breast milk (Stanya) is Upadhatu of Rasa Dhatu. Treatment of choice of Rasa Dhatu is Vamana. Breast (Stana) being abode of Stanya, Vamana is effective treatment of diseases of breast including breast cancer. Vamana Chikitsa is a sort of cleansing/detoxifying breast (Aashaya Shuddhi) and detoxification of Rasa Dhatu (Rasa Dhatu Shuddhi), which is responsible for preventing recurrence of breast cancer and metastasis.	Vamana Chikitsa was found to be beneficial in this patient to prevent recurrence, as it eliminated vitiated Kapha Dosha and Rasa Dhatu, thus imparting cleansing action of breast tissue.	Vaman improves appetite, regulates bowel habits and improves sleep pattern. It decreases LDL, serum cholesterol level and Erythrocyte Sedimentation Rate due to its Kaphahara action [25].

During this period the patient was also treated with eight sittings of periodic Panchakarma treatments i.e., medicated enemas (Basti) and induced vomiting (Vaman) [20–25 Sutrasthana 22/18, 25/40, 28/25; Sharirsthana 7/17; Vimanasthana 5/15; Chikitsasthana 15/17; Kalpasthana 1/4; Siddhisthana 1/38–39]; and monitored for healthy food and good lifestyle like early to wake-up, avoiding day sleep, not withholding natural urges (Vegavidharan), and light exercise. Details of Panchakarma treatment schedule are given in Table 3.

Table 3.

Showing date-wise period of Panchakarma treatment taken

Sr No	Set of Panchakarma Treatment	Name of Panchakarma	Period (date wise) of Panchakarma treatment
1	Set 1	Basti	16-Sep-2010 to 18-Sep-2010
2	Set 2	Basti	05-Jan-2012 to 11-Jan-2012
3	Set 3	Basti	16-Aug-2012 to 20-Aug-2012
4	Set 4	Vaman	23-Apr-2013 to 01-May-2013
5	Set 5	Basti	07-Jul-2014 to 13-Jul-2014
6	Set 6	Basti	03-Aug-2015 to 09-Aug-2015
7	Set 7	Basti	15-Feb-2016 to 17-Feb-2016
8	Set 8	Basti	01-Jul-2019 to 07-Jul-2019

6. Outcome and follow ups

Patient has taken Ayurvedic treatment in the form of OAM and Panchakarma treatment. Patient was asked to attend our OPD monthly. During his visit, he was clinically examined from Ayurvedic perspective and assessment criteria of modern medicine. OAM were given to patient at each follow-up for one month. The procedure was followed for 10 years. Panchakarma was recommended to the patient considering his eligibility to tolerate Panchakarma and season. During the course of Panchakarma, patient was admitted in our hospital and underwent the treatment under expert guidance. We never encountered any intolerance of OAM or Panchakarma in the patient.

Chemotherapy induced short - and long - term side-effects such as nausea, vomiting, loss of appetite, taste alteration, fatigue, weight loss etc. were remarkably low during and post chemotherapy. After 10 years of conventional and Ayurvedic treatment i.e., in May 2021, PET CT scan revealed no Fludeoxyglucose-18 (FDG) avid locoregional recurrence or distant organ involvement (Supplement 5). Biochemistry parameters including Hemogram, Liver Function Tests, Renal Function Tests, C Reactive Protein and Tumour marker CA 15.3 were also evaluated periodically and found to be within normal range throughout the treatment period. Karnofsky Performance Score and Quality of Life assessed yearly based on QLQ C30 and QLQ BR23 was observed to be improved during the last 10 years.

Ayurvedic parameters for assessment i.e. Ashtavidha Pariksha, Bala, Nidra, Kshudha were within normal range throughout the treatment period (Table 1)

7. Discussion

This patient presented a rare disease MBC. The reason of low incidence rate in men is due to relatively low amount of breast tissue and difference in hormonal environment than that in female [26]. However, the factors influencing malignant changes are similar.

The patient had a history of physical trauma with fractured left hand, injury to chest wall and back around 5 years before cancer diagnosis, which might have triggered the carcinogenic changes [27]. Moreover, he was at high risk of developing cancer as his paternal uncle, a first-degree relative, had liver cancer [28].

The incidence and mortality from alcohol-attributable breast cancer is already evident. Long-term cigarette smoking provided an additional clear risk for breast cancer in case of this patient [28]. Furthermore, he had several other addictions including tobacco, masheri (a pyrolyzed tobacco product), Gutakha (chewable tobacco form), apart from cigarette smoking and alcohol for more than 10 years.

In the present case, post-surgical histopathology reported a 4 cm hard invasive tumour. Total 3/14 axillary lymph nodes showed metastasis. No distant metastasis was detected. It was T2N1M0, stage IIB, grade III breast cancer as per the 8th edition of AJCC guidelines.

During chemotherapy, drugs approved by the Food and Drug Administration (FDA) for breast cancer were administered. It is well documented that chemotherapy has toxic side effects like nausea, vomiting, taste alteration, loss of appetite, etc. often causing fatigue and hampered quality of life leading to interruption in therapeutic schedule in some patients. In our earlier studies, we have established that adjunct Ayurvedic treatment has significant effect on reducing the toxic side-effects of chemotherapy drugs in cancer patients [29].

Ayurvedic understanding of the disease with respect to dimensions (Akruti), texture (Swaroop), colour (Varna), smell (Gandh) etc. of the tumour according to gross description of histopathology report is added in the manuscript. Accordingly, we have diagnosed the disease as Vama Stana Dushta Mansarbud with Vama Kaksha Dushta Granthi. In gross histopathology report, 4 cm hard tumour and 14 axillary nodes were dissected, out of which three were malignant. Causative factors of Mansavaha srotodushti like Sthula and Guru diet [19] in the form of sweet, sour, cold food items, and bakery products were consumed by the patient in substantial quantity for longer duration. Addiction of tobacco, Masheri, Gutakha, hemp and alcohol were also notable risk factors of Mansadhatwagni dushti. Thus, it is diagnosed as Vama Stana Dushta Mansarbud. Three malignant axillary lymph nodes are diagnosed as Vama Kaksha Dushta Granthi. Ayurvedic intervention and lifestyle modifications were suggested to the patient considering the Ayurvedic diagnosis.

The patient was treated with a carefully chosen combination of Ayurvedic treatment, mainly comprising Shamana Chikitsa, Rasayana Chikitsa and Panchakarma, healthy diet and good lifestyle. Shamana Chikitsa was mainly to minimize short- and long-term side effects of chemotherapy by improving appetite and digestion, reducing generalized toxicity and imparting anti-inflammatory effects, whereas Rasayana chikitsa additionally exerted immunomodulatory effect and improved quality of life of the patient. Chemotherapy induced toxicities like nausea, vomiting, diarrhoea, constipation, fatigue, fever and myelosuppression may hamper therapeutic schedule. This patient was treated with six cycles of chemotherapy along with Oral Ayurvedic Medicines namely Mouktikyukta Kamdudha Vati (MKV), Atharva Praval Pishti Vati (APPV), Atharva Ananta Kalpa and Atharva Shatavari Kalpa. These medicines were used to alleviate side-effects of chemotherapy due to their cold potency (Sheeta Guna) and Pitta pacifying property (Pitta Shamak). After completing chemotherapy, medicines like Triphala Guggulu, Arogyavardhini Vati and Chandraprabha Vati were administered for longer duration to prevent recurrence/metastasis considering their anti-cancer properties. Details of Ayurvedic principles followed in selecting Ayurvedic treatment in the form of Shaman and Rasayan chkitsa along with its mode of action are given in Table 2.

Frequent Panchakarma procedures were administered for detoxifying body and thus to prevent recurrence/metastasis. Panchakarma (body detoxifying procedure) was particularly used to eliminate deeply situated toxins in all the tissues and the organs. These procedures were accompanied by oil-based treatment modalities, strict diet and lifestyle practices. Amongst Panchakarma, Vaman and Basti are the procedures commonly recommended in breast cancer patients, which were administered to this patient [[17], [18], [19], [20], [21], [22]]. He received eight sittings of Panchakarma treatment in the form of Basti treatment with medicines having anti-helminthic activity (Krumighna Basti) for seven times and Vaman once during the period 2010 to 2019. Details of Panchakarma along with its mode of action are given in Table 2.

Short- and long-term side-effects of chemotherapy as detailed in Table 1 were assessed clinically and graded using CTCAE 4.03 Version [23] (symptom scale was of grade 1–5 with grade ‘0’ denoting absence of symptom except for fatigue is from 1 to 4). Lower scale denotes less severity of the symptoms. They were remarkably reduced and the patient could complete course of chemotherapy with good Quality of Life as per the schedule. PET scan, a diagnostic radiological tool for assessment of cancer status, showed no FDG avid locoregional recurrence or distant organ involvement in an aggressive type of MBC of this patient even after 10 years indicative of disease-free status (Supplement 5). CA 15.3 is elevated in about 80% of metastatic breast cancer patients [30]. This tumour marker and other routine biochemistry tests were within normal limits throughout the last 10 years of adjunct Ayurvedic treatment provided to him (Table 1).

The Karnofsky Performance Status, a widely used method to appraise the functional status of a patient improved from 70 to 100 during the last 10 years of adjunct Ayurvedic treatment (Table 1) [23]. The evaluation of benefit of cancer treatments is also assessed by DFS as well as the patient-reported physical or psychosocial symptoms. The later criteria are assessed by QLQ-C30 and BR 23 of EORTC, the widely used quality of life questionnaires in breast cancer research [24]. Along with symptoms like fatigue, pain, nausea/vomiting, loss of appetite, etc., it also evaluates physical and emotional status in cancer patients. Improvement in QLQ C30 Functional score from 80 to 100 and QLQ C30 Global score from 67 to 75; decrease in QLQ C30 Symptom score from 12 to 7 and BR23 score from 23 to 20 during the last 10 years of adjunct Ayurvedic treatment (Table 1) are an acknowledgment of improvement in well-being and good QoL of the patient.

Present case of male breast cancer, Stage IIB and Grade III belonged to high-grade, high-risk category with limited survival possibility. He opted for Ayurvedic treatment besides chemotherapy and continued thereafter along with hormonal treatment for the last 10 years. We, therefore emphasize that in this case, long DFS for 10 years 3 months with good quality of life and minimal side effects of cancer therapy could be due to OAM and repeated detoxifying Panchakarma treatment supported with healthy diet and good lifestyle.

The major strength of this case is that it has given a novel approach in the treatment of male breast cancer patient using adjunct Ayurvedic treatment to improve survival with good quality of life. It has served dual purpose of defining adjunct Ayurvedic treatment and also sharing the clinical experience with other health care professionals.

Limitation of case report is that a conclusion on efficacy of treatment cannot be drawn on the basis of single case. To overcome this limitation, we have to observe the benefits in a greater number of patients in future to define usefulness of such adjunct Ayurvedic treatment.

8. Patient perspective

“I, Mr PNP, was an active employee for the last 25 years in the Pune University. During this period, I started having trouble with my health. I felt a lump in my chest and it was so awkward that I didn't know whom to consult. Then one fine day my wife observed the lump and asked me what was this? That is when I told her about the distress I was going through.

I could not understand the kind of illness I was going through. Then finally I and my wife consulted a physician. On examining me, he asked whether there was any elderly person in the family. I was very nervous to hear this. My wife called my elder brother and he advised to meet one of his doctor friends. After consulting him, I was referred to Surgery. I underwent Surgery without much delay on 22nd July 2010.

My health started to deteriorate. I was not aware of my diagnosis till then, but when my elder brother asked me if I knew what had happened I said I guess I am diagnosed with Breast cancer. I requested my brother to take me to an Ayurvedic physician or I preferred dying at home. I strongly believed that only Ayurvedic treatment could help me cure from this disease. My brother took me to his Ayurvedic friend on 10th August 2010. Doctor examined me and started with the Ayurvedic treatment. I not only took oral Ayurvedic medicines but also underwent Panchakarma treatments like Vaman, Basti for a period of 7 days. I continued these Ayurvedic medicines during the course of Chemotherapy as well. They helped in minimizing the side effects of Chemo medicines and I could tolerate Chemotherapy without much difficulty. My appetite was normal, my digestion was good, I could have a sound sleep, my confidence was boosted and I could do my routine work efficiently.

Panchakarma treatment has also helped a lot in improving and maintaining a good quality life.

I was convinced of living an optimistic life and very well understood the mystery of life to deal bravely with whatever circumstances comes your way.

Today, however I am, whatever I am, I owe the credit to entire team of Ayurveda. I will always be grateful to this institute.”

Informed consent

Informed consent was taken from the patient before the treatment.

Author contribution

SPS, VD, developed the concept of integration of Ayurvedic treatment in cancer patients undergoing conventional treatments; SPS, VD, AK, VG, SG, KG, AD and SK investigated the patient as well as visualized, and validated the data curated. All authors were involved in designing the methodology of Ayurvedic and modern treatment for this patient, data curation as well as analysis of data. SG, BS, NS, DD, and VA wrote the original manuscript while the final manuscript was approved by all the authors.

Declaration of generative AI in scientific writing

The authors did not use generative AI for drafting the manuscript.

Funding sources

Bharatiya Sanskriti Darshan Trust's Integrated Cancer Treatment and Research Centre, Wagholi, Pune provided partial funding for the Ayurvedic treatment of this patient.

Declaration of competing interest

The authors declare no conflict of interest.

Appendix A. Supplementary data

The following are the Supplementary data to this article: