Table 2. Warnings issued by (a) pharmacy: lymphoma (b) pharmacy: breast cancer (c) pharmacy: other cancers.

Diagnosis	CAM taken	Other medication	Concern	Advice given
(a)
Non-Hodgkin lymphoma	Echinacea	Rituximab	Stimulation of B lymphocytes which monoclonal antibodies are targeting (Stimpel et al, 1984; Luettig et al, 1989)	Stop echinacea
			Stimulation of phagocytosis
			Increased activity and mobility of leucocytes.
			Induction of macrophages to produce cytokines (TNF, IL-1, interferon beta-2) (Stimpel et al, 1984; Luettig et al, 1989)
B-cell lymphoma	Cod liver oil	Warfarin	Cod liver oil: increase of INR with high or changing doses (Fugh-Berman, 2000)	Monitor INR
	Evening primrose oil	Sodium valproate	Evening primrose oil: decrease of seizure threshold; decrease of effectiveness of antiepileptic medication (Miller, 1989)	Discuss evening primrose oil with doctor as unclear whether Sodium valproate was taken for epilepsy
Non-Hodgkin lymphoma	Echinacea		Echinacea: stimulation of immune system as above	Stop both agents
	Kava Kava		Kava Kava: hepatotoxic (Escher et al, 2001; Russmann et al, 2001; Brauer et al, 2003; Humberston et al, 2003)
Lymphoma not specified	Echinacea	Corticosteroids, monoclonal antibodies	Stimulation of immune system as above	Stop echinacea
B-cell lymphoma	Kava Kava, Echinacea		Echinacea: stimulation of immune system as above	Stop both agents
			Kava Kava: hepatotoxic
Hodgkin's lymphoma	Echinacea		Stimulation of immune system but no interactions with Hodgkin's disease yet reported	Avoid long-term use
(b)
Breast	Ginseng royal jelly	Bendrofluazide	Ginseng: increases or decreases blood pressure (Natural Medicines Comprehensive Database (2003))	Monitor blood pressure, be aware of allergic potential of royal jelly, patient had been hospitalised with an asthma attack shortly after use, unclear whether related
			Royal jelly: allergic reactions possible if history of asthma or atopy (Leung et al, 1997; Thien et al, 1996)
Breast	Siberian ginseng	Antihypertensive therapy	Siberian ginseng: increases or decreases blood pressure (Natural Medicines Comprehensive Database (2003))	Monitor blood pressure
	Goldenseal Germanium		Goldenseal: increases of blood pressure (Natural Medicines Comprehensive Database (2003))	Stop germanium
			Germanium: case reports of renal failure, anaemia, neurological and muscular problems (Tao and Bolger, 1992)
Breast	Wild yam		Oestrogenic effect (Aradhana et al, 1992)	Stop wild yam
Breast	Evening primrose oil, Fish oil	Naproxen	Both: increase INR (Brox et al, 1981; Natural Medicines Comprehensive Database (2003))	Report any sign of bleeding
Breast	Kava Kava,		Kava Kava: hepatotoxic	Stop kava kava
Breast	Cod liver oil	Ibuprofen	Increases INR in high doses (Brox et al, 1981; Natural Medicines Comprehensive Database (2003))	Report any sign of bleeding
Breast	Beta-carotene		Increases risk of lung and prostate cancer in smokers (The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group 1994; Heinonen et al, 1998; Patrick, 2000)	Stop beta-carotene
Breast	Milk thistle, Goldenseal	Paclitaxel	Both potentially decrease Paclitaxel metabolism (Zuber et al, 2002; Daly and King, 2003; Natural Medicines Comprehensive Database (2003)	Stop both agents
(c)
Prostate	Ginkgo cod liver oil	Diclofenac	Codliver oil: antithrombotic effect, increases INR (Brox et al, 1981; Natural Medicines Comprehensive Database (2003))	Report any sign of bleeding
			Ginkgo reduces platelet adhesiveness and platelet count, increases INR (Fugh-Berman, 2000)
Ovarian	Coenzyme Q10 (ubiquinone)	Warfarin	Coenzyme Q10: reduces anticoagulant properties of warfarin, has vitamin K like effects	Unable to assess safety of combination, therefore not recommended
	Milk thistle		Milk thistle: inhibits warfarin metabolism (CYP2C9) (Heck et al, 2000; Daly and King, 2003; Natural Medicines Comprehensive Database (2003))
Oesophageal	Garlic	Aspirin, Omeprazole	May increase INR, increased risk of gastro-intestinal haemorrhage (Fugh-Berman, 2000)	Report any sign of bleeding
Testicular	Ginkgo, Garlic, Codliver oil	Aspirin	All may increase INR (Brox et al, 1981; Fugh-Berman, 2000; Natural Medicines Comprehensive Database (2003))	Report any sign of bleeding
Endometrial	Milk thistle	Doxorubicin	Potentially decreases doxorubicin metabolism (Kivisto et al, 1995)	Stop milk thistle
Ovarian	Laetrile (apricot)		Safety concern because of cyanide contents (Natural Medicines Comprehensive Database (2003))	Advised of risk and discouraged use