Pancreatic Cancer

According to Harrison’s, in 2004, pancreatic cancer killed 31,270 Americans, making it the fourth major cancer killer. (1) It is particularly virulent, killing 98% of all patients within a year of diagnosis. The cause still eludes orthodox thinkers, though over the years they have uncovered some clues. Cigarette smoking increases the risk three times, with up to 30% of cases linked to the habit. Chronic pancreatitis and obesity predispose to the illness, as does diabetes mellitus. Experts argue for a genetic component in some families, with approximately 3-9% of all cases thought due to such an inherited predisposition. (2) I remember one patient in my practice who reported six first-degree family members had died with pancreatic cancer. However, the relationship between pancreatic cancer and coffee consumption proposed some years ago and widely reported in the media has now been discounted.

Ninety percent of all cases begin in the enzyme producing (exocrine) cells of the pancreas, only 5-10% in the endocrine, hormone secreting tissue. For the most common form, adenocarcinoma of the exocrine pancreas, the conventional medical literature reports an average survival for those with metastatic disease in the range of 3-6 months from the time of diagnosis, while earlier stage patients live on average some 10-14 months. The prospects for long-term survival remain dismal whatever the stage.

In the orthodox oncology world, surgical resection of localized adenocarcinoma provides the only prospect for long-term survival, but at the time of diagnosis most patients already have evidence of widespread cancer and for them, surgery offers no benefit. Chemotherapy does little; the FDA approved gemcitabine, known as Gemzar, specifically for the treatment of pancreatic adenocarcinoma after data from clinical trials showed that patients treated with the drug lived on average 5.6 months, four weeks longer than those receiving other forms of chemotherapy. (3) Researchers did claim that in addition to this slight survival advantage, 29% of Gemzar-treated patients enjoyed an improved “quality of life,” defined as less pain, increased appetite and an overall slight enhancement of their general “well being.” Though short lived, such benefits still represented an advance over previous options for the disease. Recently, investigators at a number of academic centers have reported little additional improvement when they added other powerful chemotherapy agents into the Gemzar mix.

Scientists divide the rarer islet cell tumors into many subtypes, depending on the specific hormone released; for example, insulinomas secrete insulin, glucagonomas, glucagon, and gastrinomas, gastrin. These cancers may secrete these hormone products in dangerous amounts – frequently patients with insulinomas first seek medical advice after repeatedly fainting between meals, when excessive insulin drives so much glucose out of the bloodstream that blood sugar drops precipitously. Whatever the particular type, islet cell carcinomas tend to be less aggressive than adenocarcinomas: even patients with metastatic disease at the time of diagnosis can live five years due to its inherently slow progression, but progress it usually does, eventually with fatal results.

Dr. Isaacs and I are well known for our approach to pancreatic cancer, probably because our first clinical study evaluated our success with the disease. We published the results of this effort, funded by Nestle, in 1999. (4) Additional information about our scientific efforts is available in the “Research” section of the website. Note that none of the following patients participated in any clinical study, nor have these reports been previously available elsewhere as formal case histories.


Patient LR: A 15-year survivor

Patient LR, like so many of my patients, has an unusual background, with a graduate degree, study abroad, and expertise in art. Before we first met, he had worked successfully in business for many years. His very devoted wife had a Ph.D. and had, before retirement, worked as a college professor.

He had been in good health when in July of 1991, at age 70, a routine chest x-ray at the time of his yearly physical revealed a small right lung nodule suspicious for possible malignancy. A repeat x-ray in August 1991 again demonstrated “a parenchymal nodule in the right mid lung…” CT scan studies of the chest in late August 1991 confirmed a “6 millimeter nodule in peripheral lateral aspect of right upper lobe. It is consistent with bronchogenic carcinoma, metastatic lesion or granuloma…” In addition, the radiologist noted “an enlarged lymph node posterior to the ascending thoracic aorta…”

A CT scan of the brain in early September was clear, but a CT scan of the abdomen revealed extensive disease throughout:

There are about 4 lesions in the upper right lobe of the liver…An ultrasound examination is recommended for further evaluation…

There is a round enlargement of the right adrenal gland up to 2 cm in diameter. There is also what appears to be diffuse enlargement of the left adrenal…Both these findings are suspicious for metastatic disease. There is a mass in what may be the cephalad portion of the head of the pancreas or it is a mass or adenopathy just adjacent to the head. The mass measures about 4.5 cm in its greater diameter…

A bone scan the same day demonstrated:

Abnormal activity of the right hip and right shoulder suggesting metastatic disease…

Though the situation appeared dismal, the patient’s doctors still needed a biopsy specimen to confirm not only cancer, but also the most likely primary site. After reviewing the scans, they decided the lung lesion to be most accessible for tissue sampling, so in late September LR was admitted to his local hospital for mediastinoscopy and a limited right thoracotomy. In his admission note, the surgeon reports his belief that the situation was most consistent with metastatic pancreatic cancer, not lung cancer that had spread into the abdomen:

At some point, I suspect he will require oncology and radiation medicine consultation for what is most likely a pancreatic carcinoma with multiple metastatic lesions.

The lung nodule proved to be adenocarcinoma, as the pathology report describes:

Right upper lobe lung nodule, biopsy: Infiltrative moderately differentiated adenocarcinoma.

After surgery, an ultrasound revealed the liver lesions most likely represented metastatic cancer:

Areas consistent with metastatic involvement of the liver, the largest of which is approximately 3.4 to 4 cm in maximal dimension near the hilus. The second is just under 2 cm in the right lobe and possibly a third smaller one in the right lobe.

With the testing done, LR was told he had metastatic pancreatic cancer, perhaps two months to live, and that neither chemotherapy nor radiation would be of benefit. But, instead of giving up and getting his affairs in order as the doctors suggested, he and his wife decided to take the situation into their own hands. They both began reading voraciously about cancer, nutrition, and alternatives. He began ingesting large numbers of supplements, including vitamin C, vitamin E, even pancreatic enzymes after reading an article discussing our work. He switched his eating habits to a largely plant based, raw diet, and began juicing intensively, with his devoted wife’s help. When he felt sufficiently recovered from surgery, he decided to consult with me.

I first saw LR in December 1991. Despite his prognosis, he seemed determined to fight his disease, and talked as if he had absolute faith that he could get well on my therapy. He subsequently proved to be a very compliant patient, and the results, though gradual in coming, were gratifying. Within a year, his general health had improved substantially, and a CT scan of the abdomen in February 1993 – some 15 months after his initial diagnosis - showed no change in any of the lesions. Technically, the cancer hadn’t improved, but it hadn’t advanced, and he was still alive.

After that set of scans LR told me he wanted no more testing. Since he had already long outlived his doctors’ dismal predictions, he figured he didn’t care what the scans might show and wouldn’t change his treatment anyway. So he continued his therapy and enjoyed with his wife the retirement for which they had long planned.

In 1997, after he had followed his nutritional protocol for five years, he agreed – with some pleading from me - to allow radiographic studies. A CT of the abdomen in March 1997 showed two mildly enlarged adrenal glands and a single, very small, less than 1 cm mass in the dome of the liver. The other large liver lesions were gone. The radiologist in his report described the pancreas as normal – the previously documented large tumor had simply disappeared:

The liver demonstrated a single small hypodense area in the dome of the liver which has the appearance of a cyst, measuring well less than 1 cm. A metastatic lesion is still a possibility especially in view of the patient’s history of lung cancer and adrenal mass…The adrenal glands are both abnormal…The pancreas, the spleen and the kidneys are within normal limits. There is no evidence of periaortic lymphadenopathy.

Then sixteen months later, in July of 1998, nearly seven years after his diagnosis, LR agreed to undergo repeat scanning. The radiologist reports:

Reading the report from the 1993 study it sounded like the patient had obvious metastatic disease and the largest structure being a large porta hepatis and peripancreatic mass. No such masses are seen today. There is no adenopathy. The adrenals are prominent and there are two very small liver lesions that cannot be characterized because of their small size.

Thereafter, LR continued his program and continued doing well until he was in an automobile accident in 2004. Unfortunately, he required lengthy rehabilitation, followed by life in an assisted care facility. His wife, three years older, no longer able to care for herself at 87 years old, also entered an assisted care facility, where she recently died. But LR at age 85 years old is still alive, now more than 15 years since his diagnosis of terminal metastatic pancreatic adenocarcinoma.

His case does not require much discussion. He was diagnosed appropriately with terminal cancer and given two months to live. He did his program, the tumors went away, and he survived.

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Patient IR: A Ten-Year Survivor

In 1985, Patient IR had undergone surgery for localized colon cancer but subsequently received no adjuvant radiation or chemotherapy for the disease. He thereafter did very well until he developed a large right neck mass about the size of a golf ball in October 1996 while traveling outside the country. Upon returning to the United States in December 1996 he underwent a biopsy which confirmed “adenocarcinoma.” His doctors assumed the cancer had metastasized from some abdominal organ, though they weren’t initially certain which one. IR then traveled to Memorial Sloan-Kettering in New York, where he was seen in early January 1997. There, after the biopsy slides were reviewed and adenocarcinoma confirmed, the pathologist reported the neck disease most likely represented metastasis from a new primary tumor, not recurrent colon cancer, as the note describes:

Metastatic poorly differentiated adenocarcinoma with focal signet ring cell features to lymph node. Possible primary sites include lung, stomach and pancreas.

IR then underwent CT scanning of the chest and abdomen as well as bronchoscopy, all of which were unrevealing. A CT scan of the neck demonstrated “Pathologic appearing adenopathy within the right posterior triangle.”

A PET scan a week later revealed:

1. Abnormal FDG Pet scan showing focal FDG uptake in the right posterior neck, consistent with lymph node metastasis.

2. Focal uptake seen in the right upper quadrant, just anterior to the right kidney, may be due to primary tumor. The location could be in the head of the pancreas or the second part of the duodenum…

At this point, after the Memorial doctors concluded the primary to be most likely pancreatic cancer, they suggested a conservative approach, holding off treatment until the disease further advanced. However, IR had learned of our treatment approach, decided to proceed with us, and first consulted with me in January 1997. Thereafter, he followed his program diligently, with good results. Follow up MRI’s of the abdomen and pelvis at Memorial in July and October 1997 revealed no evidence of cancer anywhere. The October report reads:

Since the previous study of 7---97:
1. No significant interval change is appreciated.
2. No evidence for neoplasm in the abdomen.
3. No abnormalities are identified in the pelvis.

Subsequently he continued his aggressive protocol for three years, before winding down to a maintenance regimen. Today, nearly ten years after he started his nutritional regimen, he appears to be in excellent health, enjoys retirement, and remains free of his once life threatening cancer.

Like the previous patient, this case is very straightforward. Biopsy confirmed metastatic carcinoma, considered by the Memorial experts most likely, based on the PET scan, to be of pancreatic origin. The patient followed his regimen faithfully, subsequent scans showed no evidence of disease, and he remains cancer free to date

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Patient CI: A 10.5-Year Survivor

Patient CI had been previously very healthy when he first developed chronic heartburn, gradual weight loss and persistent diarrhea throughout the summer of 1992. In August of that year, he became suddenly very weak and short of breath; when his local doctor found him to be anemic, he was hospitalized for a transfusion. An endoscopy showed multiple stomach ulcers, thought to be the source of the blood loss. Additional testing revealed elevated blood levels of the hormone gastrin, which was assumed to be responsible for the ulcerations. Usually, excess blood gastrin warns of a hormone secreting pancreatic tumor, but despite extensive testing, no such lesion could be found. So, after prescribing Prilosec, his doctors sent CI home.

On the medication he actually did fairly well, with no further bouts of severe anemia until October 1994 when his gastrin levels on routine blood testing were again elevated. This time around, a CT scan did show a 6 to 7 cm mass in the retroperitoneal area of the abdomen. After a series of delays, he underwent exploratory abdominal surgery in March of 1995 at a local hospital; unfortunately, his surgeon discovered a very large tumor that because of its size and degree of infiltration throughout the pancreas could not be removed, though it was biopsied. In addition, a metastatic lesion at the base of the liver was resected. The operative note describes the extent of disease:

There was however a large uncinate process grossly clinically involved with tumor. Also, the whole head of the pancreas clinically was involved with tumor as well. Lateral to the head of the pancreas on the other side of the SMV and the neck and body region was also palpable tumor.

Palpation and exploration of the porta hepatis revealed approximately a 3 cm mass noted…This was sharply dissected and free (sic) and sent to pathology for quick frozen section…

The pathology report confirms that the pancreatic and portal lymph node biopsies were consistent with “Metastatic carcinoid-islet cell tumor.”

After recovering from surgery, CI decided to travel for a second opinion to the Mayo Clinic, where he was seen in May of 1995. At Mayo, the original slides were reviewed, and the diagnosis of islet cell carcinoma verified. At the time, the consulting oncologist recommended no additional therapy as the official Mayo note reads:

I briefly discussed the case with my surgical colleague, Dr. ----. He did not feel that any further surgical intervention was warranted at this time. A Whipple procedure would be entirely palliative at this time. The patient may eventually come to a bypass procedure as there is some bile duct dilatation on CT scan. We discussed the fact that there is no good evidence for benefit from radiotherapy…I discussed with him the role of chemotherapy in patients with islet cell carcinoma...there is no evidence that earlier treatment will show improved response and survival. Given his asymptomatic state, I did not recommend any intervention at this time…

Initially, CI continued only on his Prilosec. By early 1996, he wasn’t content to wait until the disease progressed, so he began investigating alternative cancer therapies. After learning of my work, he first came to my office in March of 1996 and subsequently proved to be determined, very diligent and very disciplined with his nutritional regimen.

In June 1997, a little over a year after he first began treatment, his local doctor sent him for a follow-up CT scan to check his progress. The radiologist reported “no significant change in the appearance of the patient’s pancreatic mass since previous examinations.” The tumor was still there, but no bigger.

For several years, since he felt so well, he avoided any testing until agreeing to another scan in September 2002. The official report stated:

Findings: Images of the pancreas demonstrate no mass lesions. The liver, spleen adrenal glands and kidneys are unremarkable.

Impression:
1. Normal CT scan of the abdomen.

The large tumor in his pancreas had simply gone away. A more recent scan was also completely clear, and today, ten years after beginning his nutritional therapy, CI continues on his program and continues doing well.

This is not a complicated case. CI at surgery was found to have unresectable disease that had metastasized to the porta hepatis lymph nodes. Biopsies of the large pancreatic mass and the metastatic lesion revealed islet cell carcinoma, findings confirmed at the Mayo Clinic. CI then began my program, followed it faithfully, his tumors went away, and he remains cancer free and in excellent health, 10.5 years from his original diagnosis.

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Patient RB: A Six-Year Survivor

In November of 2000, Patient RB first reported a gradual 25-pound weight loss to her local physician. A CT scan of the abdomen in early December 2000 revealed a 3.4 cm mass in the head of the pancreas, but no evidence of metastatic disease. A subsequent CT scan guided needle biopsy in February 2001 confirmed a “Poorly differentiated adenocarcinoma, ductal type,” the most aggressive form of pancreatic cancer. The slides were also sent to the Mayo Clinic, where the consulting physicians agreed with the histological diagnosis.

Since the disease seemed localized to the pancreas, the patient’s physicians thought the tumor might be operable. She was urged to undergo extensive surgery, but the patient decided the risks were too great, the potential benefits too meager, to warrant such an approach. She subsequently learned of our approach and in March 2001, consulted with Dr. Isaacs in our office. In April 2001, a month after she began her nutrition treatment, repeat CT scans revealed a 3.2 cm mass in the head of the pancreas, with no evidence of metastatic disease.

A follow-up CT scan performed in January 2002, some ten months after she began treatment with Dr. Isaacs, indicated a 3.0 x 3.0 cm mass in the head of the pancreas, smaller compared to the scan of April 2001. The next CT in July 2003, after RB had followed her nutritional regimen for more than two years, showed a 3.16 x 2.6 cm mass in the head of the pancreas, and a scan not quite a year later revealed a 3 x 2.8 cm mass.

RB, now a six-year survivor, currently is in good health despite her original poor prognosis. In her case, the CT scans show perhaps some slight shrinkage in her tumor, but no spread. Given the aggressive nature of pancreatic adenocarcinoma in general, and the virulent nature of the poorly differentiated variety diagnosed in this case, its tendency to metastasize and kill within a year even when aggressively treated, this patient’s course has truly been remarkable. She has been able to avoid aggressive surgery, chemotherapy, and radiation while enjoying excellent health.

As a side note, we do find in our practice that though tumors often disappear – as in the previously discussed cases of pancreatic cancer - at times they seem to stabilize, sometimes for many years.

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Patient CX: A Five and a Half-Year Survivor

Patient CX, with a long history of GERD (gastroesophageal reflux disease) decided in January of 2001 to undergo laparoscopic surgery for correction of what was presumed to be a simple hiatal hernia. During the procedure, his doctor discovered “multiple umbilicated, white, firm, and gritty tumors in both the right and left lobes of the liver, apparently occupying approximately 50% of the volume of the liver.”

A biopsy of one of the liver lesions confirmed “poorly differentiated metastatic carcinoma,” with some “neuroendocrine differentiation.” The final diagnosis reads

Liver needle biopsy
Positive for malignancy, favor metastatic adenocarcinoma.

After surgery, a CT of the chest, abdomen, and pelvis revealed a large 6.5x3.7 cm mass in the tail of the pancreas, with “diffuse hepatic metastases.” The radiologist wrote “This likely represents primary pancreatic adenocarcinoma.”

The patient subsequently met with an oncologist at Barnes Hospital who suggested aggressive chemotherapy with cisplatin and etoposide for 4 cycles, though he admitted that even with chemotherapy, the disease would ultimately progress and prove deadly. Before agreeing to the treatment, in February of 2001 CX traveled to Memorial Sloan-Kettering in New York for a second opinion. There, the Memorial pathologists reviewed the slides and confirmed a very aggressive pancreatic carcinoma. The consulting oncologist then proposed the same chemotherapy protocol that had been previously recommended but again warned that even with aggressive treatment, CX might live at most two years. Chemotherapy, as he had been told before, might shrink his tumors and prolong his life, but would not provide a long-term solution.

At the time of the Memorial consultation, CX was not doing well clinically. The official note states:

The patient has significant fatigue, takes naps usually by the end of the afternoon. He does notice recent onset back pain which is alleviated with pain pills. He has significant nausea without vomiting….He does have occasional palpitations but denies flushing. He notes mildly decreased appetite and has had an approximately ten-pound weight loss.

After returning home, CX began the proposed course of chemotherapy in February 2001 administered by his local oncologist. After his first cycle, a CT scan in February 2001 indicated some response to chemotherapy:

As on the prior examination, there is a low attenuation mass within the tail of the pancreas. The mass is smaller is size, measuring 6.4 cm x 3.0 cm on the current examination….on today’s study there are innumerable low attenuation lesions throughout the liver, measuring up to 2 cm in diameter, consistent with metastatic disease…

After the second cycle of chemotherapy, a repeat CT scan in March 2001 showed:

1. Marked improvement in numerous liver metastases with a decreased (sic) in size as well of the pancreatic tail mass.

CX completed the first 3 cycles of chemotherapy without much difficulty, but during the 4th round he became so ill the drugs had to be discontinued in April of 2001. Then, after learning about our work, he decided to forgo further chemotherapy and proceed with our treatment.

I first saw CX in my office in May 2001, a month after his last round of drugs. Thereafter CX proved to be very compliant with his nutritional regimen and within months he reported significant improvement in his general health. His many symptoms, including persistent debilitating fatigue, had resolved.

A CT of the abdomen in February 2002, 10 months after he had first come to our office, indicated multiple small lesions in the liver, which had been seen on previous scans, as discussed in the official note:

1. Multiple tiny lesions in the liver, all less than 3 mm in size. Some of these lesions have been noted on prior studies which were obtained at slightly larger collination (calibration) and have not changed since the previous studies.

2. No pancreatic lesion

3. No abdomen or pelvic lesion.

At that point, I made several adjustments in his regimen. A repeat CT scan in October 2002, some 17 months after he had first begun his nutritional therapy, confirmed that all the liver tumors were gone. The report states:

1. No pancreatic lesion identified.

2. Multiple tiny lesions in the liver seen on the prior examination are not identified on today’s study.

Follow up scans in March 2003 and June 2004 were also completely clear. His most recent scan in March 2005 revealed:

The liver, gallbladder, pancreas, spleen and both kidneys appear unremarkable…

He has been following his program for 5.5 years and is nearly six years from his original diagnosis of very advanced and very terminal pancreatic carcinoma. He remains disease free.

This case, like the previous four, is not complicated. Though aggressive chemotherapy did shrink the primary pancreatic as well as the liver tumors, the disease did not completely regress on drug treatment. Futhermore, the experts he consulted at Barnes and Memorial Sloan-Kettering warned him even if he showed some response, the benefit would be short lived. No one, even the most fanatical oncologist, claims chemotherapy cures pancreatic carcinoma metastatic to the liver. Finally, it was only on his nutritional regimen that the tumors regressed completely and stayed that way.

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Patient ZR: A Twenty-Four-Year Kelley Survivor

I first learned of Patient ZR while reviewing the records of patients with pancreatic cancer treated by Dr. Kelley. I thought I would include her to illustrate the kind of successes uncovered in Dr. Kelley’s files, as I pursued my five-year study of his therapy.

In early 1980, ZR first experienced occasional bouts of mid-abdominal pain that gradually worsened over a two-year period. Despite the symptoms, she did not seek medical assistance until August 1982, when she was admitted to the local emergency room of her Midwest town with excruciating pain. When an ultrasound showed only gallstones, her doctors assumed she might be suffering from gallbladder disease and proposed cholecystectomy.

Several days later, she underwent exploratory surgery and removal of the gallbladder. However, the surgeon also discovered a pancreatic mass that had invaded into the surrounding tissues, as well as a single 1 cm tumor in the liver, which he biopsied. Due to the extent of disease, he made no attempt to excise the pancreatic tumor.

The liver specimen proved consistent with adenocarcinoma that had spread from a pancreatic primary. After recovering from surgery, ZR met with an oncologist, who told her that although chemotherapy might prolong her life slightly, no treatment could cure her disease. He suggested she get her “affairs in order.” In the official records, this physician wrote: “The patient's prognosis is judged to be between 9 and 15 months at most.”

After recovering from surgery, ZR decided to seek out a second opinion at the Mayo Clinic in Rochester, Minnesota. When seen at Mayo in mid September, a CT scan revealed an enlarged pancreas, and blood studies indicated abnormal liver function tests. At the conclusion of his evaluation, the consulting oncologist wrote, in the official discharge summary:

I had a long discussion with her regarding treatment for her cancer. At the present time I would favor simply observation since we know of no known treatment that will necessarily prolong her life. Since she is feeling well at the present time I did not feel justified in making her symptomatic from the side effects of chemotherapy.

Fortunately, ZR learned of Dr. Kelley’s work from a local health food store owner, and shortly thereafter began treatment with him in December of 1982. She responded quickly, and within six months was back to working long days in the family business.

By the time I completed my study in 1987, Dr. Kelley had closed down his office and disappeared from sight. After I started my own practice, I lost touch with ZR until she referred a patient to me in the mid-1990’s. At that time she was in excellent health 15 years out from diagnosis, still following her prescribed diet and still taking pancreatic enzymes. I heard recently that she is still alive, still active, and still enjoying her life, now 24 years from her original Mayo confirmed diagnosis of metastatic adenocarcinoma of the pancreas.

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1. Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo, DL, Jameson JL. Harrison’s Principles of Internal Medicine, 16th Edition. New York: McGraw-Hill; 2005:537.

2. DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles and practice of oncology, 6th Edition. Philadelphia: Lippincott Williams & Wilkins; 2001:1127.

3. Burris HA, Moore MJ, Andersen J, Green MR, Rothenberg ML, et al. Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial. J Clin Oncol. 1997;15:2403-13.[Abstract]

4. Gonzalez NJ, Isaacs LL. Evaluation of Pancreatic Proteolytic Enzyme Treatment of Adenocarcinoma of the Pancreas, With Nutrition and Detoxification Support. Nutr Cancer. 1999;33:117-24. [Abstract]


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Nicholas J. Gonzalez, MD PC
Linda L. Isaacs, MD
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