H was given a protocol to follow with goals of alleviating side effects; the modalities included nutrition, hydrotherapy, supplements, and exercise. A whole foods diet was implemented for weight optimization. The diarrhea was treated with eating organic yogurt and kefir as a source of probiotics. L-glutamine powder 7 g/d was recommended for rebuilding the gut as well as treating diarrhea. Zinc gluconate 20 mg/d was added for the restoration of taste. The CIPN was treated with Neurosol at one softgel twice daily.(4) The hydrotherapy consisted of home treatments including warming socks and gloves nightly to increase peripheral circulation and Epsom salt soaking baths twice weekly. The exercise protocol was a daily walk for 20 minutes. When H presented for the 11th cycle of FOLFOX, the peripheral neuropathy had completely resolved as determined by patient interview before administration of the chemotherapy. At this point H had received a cumulative dose of oxaliplatin of approximately 850 mg/m2. The dose-limiting neurotoxicity occurs with a cumulative dose between 780 and 850 mg/m2 in oxaliplatin treatment.(3) At no point during the remaining nine cycles (cycles 12-20) did H present with complaints of CIPN. The CIPN treatment of Neurosol and home hydrotherapy was continued throughout the FOLFOX treatment and discontinued after the last cycle of FOLFOX, October 2004. (Figure 1) H had excellent partial remission and was switched to irinotecan and bevacizumab, and later cetuximab. The partial remission continued through June 2005. Unfortunately, by October 2005 the cancer was found to be progressive as evidenced by CT scan and CEA (carcinoembryonic antigen) levels rising. At this point, a second round of FOLFOX (13 cycles) was started April 2006. The oxaliplatin dose was 85 mg/m2 with a cumulative dose of approximately 1000 mg/ m2. On two of the cycles the oxaliplatin dose was reduced to 75 mg/m2 due to neutropenia, but not reduced due to neurotoxicity or CIPN. H resumed a similar protocol as for the first FOLFOX treatment, including the same diet therapy of whole foods and yogurt, and a meal of organic liver and onions 1-2 times weekly to guard against chemotherapyinduced anemia. Other therapies included Epsom salt baths, Neurosol (one softgel bid), omega-3 fish oil capsules, and one tablet of silymarin 80% bid (equal to 56mg silymarin/tab). The use of silymarin is currently in question with regards to potential interactions from hepatic metabolism of other medications the patient may be on. The specific concern is that silymarin modulates the activity of cytochrome P450 enzymes and may increase the levels of toxic medications in a patient. 5 The silymarin was prescribed for liver health due to the progressive metastatic cancer in the liver. The FOLFOX combination contains three medications, none of which are hepatically cleared,6 so the use of silymarin was not contraindicated in this patient.

Since H began naturopathic integrative care his weight stabilized and was considered healthy for his height (+/- 5 pounds) for 15 months while undergoing chemotherapy. In addition, the patient experienced a complete elimination of the CIPN. The Neurosol was discontinued after recovery from the neuropathy and this symptom had not returned as of December 2006. H has had regular bowel movements without significant constipation or diarrhea with the exception of chemotherapy days when he experienced one day of diarrhea that affected daily activities. This is a reduction from seven days of diarrhea post chemotherapy before initiating integrative medical care.

In August and September 2006, while undergoing FOLFOX treatments, H enjoyed fishing trips to British Columbia and a vacation to Puerto Vallarta. H has had enough energy to be able to exercise and take pleasure in life. After the 13th cycle of FOLFOX in October 2006, H met with the oncologist and in a review of symptoms had no fevers, unusual anorexia, weight loss, peripheral neuropathy, unusual aches or pains, anxiety, depression, or rashes. There are limitations to this case report. No validated tools were used to objectively evaluate the quality of life, ADLs, and CIPN. The data was retrieved through interview and chart notes from the physicians caring for H. In summary, during the naturopathic care that the patient received, H experienced a reduction in all major side effects from the chemotherapy, increased quality of life as evidenced by the ability to not only leave the house, but also to take vacations and engage in hobbies that were previously difficult.