Omega-3 Fatty Acids

We’re busy updating our review of omega-3 fatty acids and will provide a rating when that’s complete. While we’re working, we share a summary from our predecessor website, Beyond Conventional Cancer Therapies. The information we share here was last updated in August 2021.

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Omega-3 Fatty Acids

Key Points

• Before using this therapy, consult your oncology team about interactions with other treatments and therapies. Also make sure this therapy is safe for use with any other medical conditions you may have.
• Omega-3 fatty acids are found naturally in many fish and a few seeds and walnuts.
• Omega-3s are widely available as supplements.
• BCCT is interested in omega-3s because evidence shows benefits in several types of cancer treatment, and preliminary evidence shows omega-3s may reduce risks of breast and colon cancer.
• While omega-3s are generally considered safe, a few cautions and interactions are noted.

Omega-3 fatty acids are a type of polyunsaturated fatty acid (PUFA) found naturally in these foods and supplements:

• Fish and fish oil: anchovies, bluefish, herring, mackerel, salmon (wild has more omega-3s than farmed), sardines, sturgeon, lake trout and tuna1
• Krill oil
• Cod liver oil
• Flaxseed oil
• Linseed oil
• Walnuts
• Chia seeds

The three main omega-3 fatty acids are docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA) and alpha-linolenic acid (ALA). DHA and EPA generally show greater benefits in cancer, but are found only in animal sources. ALA from plant sources is converted to DHA and EPA in our bodies, but with a low conversion efficiency. ALA is not recommended as your sole source of omega-3s.2

Clinical Practice Guidelines

Society for Integrative Oncology

Clinical practice guidelines from the Society for Integrative Oncology (SIO) suggest oral supplementation with omega-3 fatty acids to improve the nutritional status in people with lung cancer who have lost muscle mass (sarcopenia).3

American College of Chest Physicians

2013 evidence-based clinical practice guidelines from the American College of Chest Physicians recommended oral nutritional supplementation with omega-3 fatty acids to improve the nutritional status for lung cancer patients with sarcopenia (loss of muscle tissue).4

Treating the Cancer

Working against cancer growth or spread, improving survival, or working with other treatments or therapies to improve their anticancer action

General Cancer

No improved survival with supplementation5

Breast Cancer

• Improved survival and other outcomes with omega-3s used with chemotherapy in a trials of people with metastatic6
• Reduced all-cause mortality (but not with early stage breast cancer) with marine omega-3s from food but not supplements7
• No adverse side effects and possible improved anthracycline-based chemotherapy outcome in a small uncontrolled trial of group patients with rapidly progressing visceral metastases8

Colorectal Cancer

• Improved survival with a diet rich in omega-3 fatty acids9 or omega-3s from both diet and supplements10
• No reduction in mortality when taken before gastrointestinal cancer surgery in a nutritional supplement also including arginine and nucleotides11
• No decrease in tumor size or improvement in patient survival times with supplementation12
• Increased cell death (apoptosis) in the normal sigmoid colon with a dietary decrease in omega-6s and increase in omega-3s for two years13
• Eicosapentaenoic acid (EPA) effects:
  • Improved overall survival in patients undergoing liver resection surgery for colorectal cancer liver metastases14
  • Reduced extent of blood vessel networks consistent with reduced creation of new blood vessels to supply tumors (angiogenesis) with EPA use15
  • Reduced crypt cell proliferation and increased cell death (apoptosis) in people with colorectal adenomas with three months of supplementation16

Prostate Cancer

• Smaller prostates (both benign and malignant components), lower proliferation index, and plasma that inhibited growth of prostate cancer cells in vitro more than the plasma in a group of men with prostate cancer combining omega 3 supplements with a low-fat (15 percent of calories from fat) diet for four to six weeks before prostatectomy17
• Decreased prostate cancer proliferation and decreased omega-6:omega-3 ratios in prostate tissue, but no change in serum insulin-like growth factor I (IGF-1) in a small study of men undergoing radical prostatectomy18
• No impact on prostate-specific antigen levels among people with prostate cancer taking fish oil supplements19

Lab and Animal Evidence

Managing Side Effects and Promoting Wellness

Managing or relieving side effects or symptoms, reducing treatment toxicity, supporting quality of life or promoting general well-being

Anxiety

Mixed results among people with conditions other than cancer:

• Lower scores for anxiety among people with with heart attacks (acute myocardial infarction) with omega-3 fatty acids in a small RCT26
• Lower anxiety scores among healthy medical students with both EPA and DHA in a small RCT27
• Lower scores for anxiety and anger among people who are substance abusers and whose dietary intakes of omega-3s were below recommended levels; EPA levels showed more impact with anxiety in a small RCT28
• No impact on anxiety scores among people with obsessive-compulsive disorder with EPA in a small RCT29
• Lower scores during menopause, but only in the absence of depression30
• Lower scores and duration of anxiety among women experiencing symptoms of premenstrual syndrome in a mid-sized RCT31 
• Lower scores on several measures of anxiety, including cortisol levels, among students with test anxiety after three weeks of supplementation with both omega-3 and omega-6 fatty acids (1:4 ratio), with apparently (but not analyzed) more improvement than students receiving placebo in a small trial32

Body Weight and Composition

• Omega-3 fatty acid (EPA and DHA) capsules or supplements with EPA have been associated with weight stabilization, gain in lean body mass, and improvement in quality of life markers in patients losing weight as a result of advanced pancreatic and head and neck cancers.33
• Promoted weight maintenance or gain during cancer treatment, and improved scores of physical function and global health status with omega-3s34 or EPA alone, with a trend toward fewer interruptions of chemotherapy treatment35
• Maintained36 or benefited37 body weight during chemotherapy
• Increased weight of patients with gastrointestinal cancer (anal, colorectal, esophageal, stomach) with EPA supplementation.38
• EPA and DHA reduced muscle loss and myosteatosis (the presence of intermuscular and intramuscular adipose tissue) in clinical studies.39
• EPA increased mean weight and energy levels in an uncontrolled trial of colorectal cancer patients undergoing chemotherapy with folinic acid, 5-fluorouracil, irinotecan (FOLFIRI)40
• Reduced weight loss in cancer patients receiving chemotherapy after surgical tumor (mainly gastrointestinal) removal with fish oil supplementation41
• Omega-3 supplements improved outcomes, especially body composition, in patients undergoing chemotherapy and/or radiotherapy.42
• EPA reduced deterioration of nutritional status resulting from antineoplastic therapies (therapies to block the formation of neoplasms) by improving calorie and protein intake43
• Increased lean-body mass, decreased resting energy expenditure, improved performance status in patients with cachexia (weakness and wasting) and improved appetite with a combintation therapy of medroxyprogesterone or megestrol acetate, eicosapentaenoic acid (EPA), L-carnitine and thalidomide44
• Improved chemotherapy-related appetite loss with a combination omega-3 fatty acid and microbial cell preparation45

Depression

• Pure eicosapentaenoic acid (EPA) or an EPA/docosahexaenoic acid (DHA) combination of a ratio higher than 2 (EPA/DHA >2) are considered effective, according to the International Society for Nutritional Psychiatry’s consensus-based practice guideline for clinical use of omega-3s in major depressive disorder (although not specific to people with cancer).46
• Lower scores and duration of depression among women experiencing symptoms of premenstrual syndrome in a mid-sized RCT47
• Lower scores for depression among people with with heart attacks (acute myocardial infarction) with omega-3 fatty acids in a small RCT48

Fatigue

• Reduced cancer-related fatigue in people with breast cancer increasing dietary omega-3 fatty acids combined with guarana extract and a diet rich in whole foods, fruits and vegetables49
• Improved fatigue with a combintation therapy of medroxyprogesterone or megestrol acetate, eicosapentaenoic acid (EPA), L-carnitine and thalidomide50
• Relieved chemotherapy-related fatigue with a combination omega-3 fatty acid and microbial cell preparation51

Gastrointestinal Effects, including Nausea and Vomiting

• Relieved chemotherapy-related nausea and vomiting and diarrhea with a combination omega-3 fatty acid and microbial cell preparation52

Pain

• Improved chemotherapy-related pain with a combination omega-3 fatty acid and microbial cell preparation53

Peripheral Neuropathy

• Reduced paclitaxel-induced peripheral neuropathy people with breast cancer54
• Reduced incidence of peripheral neuropathy in one review,55 but another review found insufficient evidence yet exists to recommend use for treating or preventing chemotherapy-induced peripheral neuropathy (CIPN)56

Stress

• Stable scores of rated anger and confusion during a stressful task with omega-3 supplementation among young adults, whereas controls receiving a placebo had rising anger and confusion, but no further effects on mood, cognitive function, cortisol, or IL-1β in a mid-sized RCT57
• Decrease in stress/anxiety ratings, accompanied by reduced cortisol basal levels throughout the day, among male alcoholics undergoing residential rehabilitation with EPA and DHA compared to controls in an RCT58

Other Side Effects and Symptoms

• Improved function of blood neutrophils in cancer patients receiving chemotherapy after surgical tumor (mainly gastrointestinal) removal with fish oil supplementation59
• Less dry mouth (xerostomia) among women with advanced breast cancer undergoing neoadjuvant chemotherapy with adriamycin/cyclophosphamide60
• High-dose EPA inhibited bone resorption in breast cancer survivors taking aromatase inhibitors.6162
• Reduced postoperative infectious complications and hospital stay after colorectal cancer surgery in one study63 but no improvement in infectious or non-infectious postoperative complications in another64
• Improved quality of life with a combination omega-3 fatty acid and microbial cell preparation65
• Possibly shorter hospital stay with supplementation after oncology surgery66
• Reduced infectious complications, length of hospital stay and co-morbidities in cancer patients undergoing surgery with supplementation with omega-3 fatty acids, arginine and nucleotides67

Reducing Risk

Reducing the risk of developing cancer or the risk of recurrence

Breast Cancer

• Higher omega-6 to omega-3 ratios are associated with higher risk of breast cancer,68 while omega-6/omega-3 ratio of 2-4:1 are associated with a reduced risk.69
• Reduced risk with higher omega-3 levels from combined diet and supplements are associated with lower risk of breast cancer.70
• Higher consumption of dietary marine omega-3 polyunsaturated fatty acids is associated with a lower risk of breast cancer.71
• No impact of supplements on breast cancer recurrence with early stage breast cancer, but marine omega-3s from food were associated with reduced risk of additional breast cancer events.72
• Higher levels from combined diet and supplements are associated with reduced risks of breast cancer.73 No impact of supplements was found on breast cancer recurrence in patients with early stage breast cancer, but marine omega-3s (DHA and EPA) from food were associated with reduced risk of additional breast cancer events.74
• Reduced risk of breast cancer with consumption of omega-3 long-chain polyunsaturated fatty acids (LCPUFAs) and an omega-6/omega-3 ratio of 2-4:175

Colorectal Cancer

• Decreased risk of colorectal cancer with increased consumption of omega-3 fatty acids in fish76
• Decreased risk of colon cancer with fish oil supplements,77 especially in men, but an increased risk was found with individuals with high genetic risk78
• Decreased risk of distal large bowel cancer with lower ratios of omega-6 to long-chain omega-3s, but only in Americans of European descent, and not among Americans of African descent79
• Reduced number and size of rectal adenomas80
• Reduced risk of colon cancer with consumption of omega-3 long-chain polyunsaturated fatty acids (LCPUFAs) and an omega-6/omega-3 ratio of 2-4:181
• EPA alone:
  • Reduced number and size of polyps in patients with familial adenomatous polyposis with eicosapentaenoic acid (EPA) alone82
  • No reduction in the proportion of patients with at least one colorectal adenoma in patients with sporadic colorectal neoplasia, used either with or without aspirin, compared with a placebo83

Kidney Cancer

• Reduced risk of kidney (renal) cancers with consumption of omega-3 long-chain polyunsaturated fatty acids (LCPUFAs) and an omega-6/omega-3 ratio of 2-4:184

Lung Cancer

• Decreased risk of lung cancer with omega-3 supplementation85

Prostate Cancer

Data on omega-3 fatty acid supplementation for prostate cancer prevention are inconclusive.

• A 2017 review of the literature showed no clear relationship between fish-derived omega-3 fatty acids and risk of prostate cancer86
• A separate review found a reduced risk prostate cancer with consumption of omega-3 long-chain polyunsaturated fatty acids (LCPUFAs) and an omega-6/omega-3 ratio of 2-4:187

Lab and Animal Evidence

Optimizing Your Terrain

Creating an environment within your body that does not support cancer development, growth or spread

• Reduced inflammation,89 or improved anti-inflammatory markers90 including when accompanying anticancer treatment91 and in patients undergoing radical colorectal cancer resection92
• Lower markers of inflammation among healthy medical students with both EPA and DHA in a small RCT93
• Improved immune functions in cancer patients undergoing surgery94

Modes of Action

Four mechanisms are identified:95

• Inflammatory response
• Brain-derived neurotrophic factor (BDNF)
• Cortisol
• Cardiovascular activity

Cautions

A few cautions are noted. Please see the Memorial Sloan Kettering Cancer Center’s  About Herbs website for more information.

• High blood concentrations of omega-3s are associated with increased risk of prostate cancer (see the see the Foundation for Alternative and Integrative Medicine for an analysis of the study that found this for an analysis of the study that found this).
• Increased resistance to chemotherapy is a concern;96 a type of omega-3 fatty acid, 16:4(n-3), can reduce the activity of the chemotherapy drug cisplatin. Use is not recommended on the days surrounding chemotherapy.97
• 2018 review conclusions:98
  • Four grams of supplementation may impair clotting; patients may want to eliminate omega-3 supplements before and immediately after surgery.
  • A few adverse reactions and interactions with prescription and other drugs have been observed.

Dosing

CancerChoices does not recommend therapies or doses, but only provides information for patients and providers to consider as part of a complete treatment plan. Patients should discuss therapies with their physicians, as contraindications, interactions and side effects must be evaluated. Levels of active ingredients of natural products can vary widely between and even within products. See Quality and Sources of Herbs, Supplements and Other Natural Products.

Dosage recommendations are available from these sources:

• Natural Medicines Database (requires purchase)
• Also see the protocols listed below.

Integrative Programs, Protocols and Medical Systems

For more information about programs and protocols, see our Integrative Programs and Protocols page.

• Programs and protocols
  • Alschuler & Gazella complementary approaches99
    • Breast cancer
    • Colon cancer
    • Lung cancer
    • Pancreatic cancer
    • Prostate cancer
  • Block program100
    • Breast cancer case study
    • Lung cancer case study
    • Prostate cancer case study
    • Core diet plan
    • Remission support diet
    • Chemotherapy coupler
    • Radiation therapy coupler
    • Normalizing coagulation
    • Blocking inflammation
    • Blocking tumor-fueling enzymes
    • Boosting immune surveillance
    • Self-care program for stress chemistry and circadian rhythm
  • Chang strategies101
  • Lemole, Mehta & McKee protocols102
    • Breast cancer
    • Colorectal cancer
    • Endometrial cancer
    • Lung cancer
    • Prostate cancer
  • MacDonald breast cancer program103
  • McKinney protocols104
    • General cancer
    • Breast cancer
    • Leukemia amd myelodysplastic syndrome
    • Melanoma
    • Prostate cancer
    • Sarcoma
    • Thyroid cancer
    • Depression
    • Fatigue
    • Weight loss
  • Parmar & Kazcor treatment plans105
  • Traditional systems
    • Ayurveda
    • Traditional Chinese medicine

Note: CancerChoices has not conducted an independent review of research of Omega-3 fatty acids. This summary draws from the Memorial Sloan Kettering Cancer Center’s About Herbs and other sources as noted.

Also known by these names

• O3FAs
• ω-3 fatty acids
• n-3 fatty acids
• omega 3s
• Individual O3FAs:
  • Docosahexaenoic acid (DHA)
  • Eicosapentaenoic acid (EPA)
  • Alpha-linolenic acid (ALA)

Helpful links

• Memorial Sloan Kettering Cancer Center’s About Herbs website: Omega-3
• Deng G, Gubili J. Omega-3 Fatty Acids. ASCO Post. March 10, 2019.
• American Institute for Cancer Research website: more than 100 articles and scientific reports on omega-3 fatty acids and cancer
• TRC Natural Medicines website (subscription is required): in-depth information, ratings of effectiveness and safety and evaluation of specific omega-3 fatty acid products   
• Consumer Labs: Product Review (subscription required): Fish Oil and Omega-3 and -7 Fatty Acids Supplement Review
• Moss Reports (purchase required): Select from the list of cancers down the left side of the page for a report describing uses of conventional, complementary, alternative and integrative therapies related to that cancer. Ralph Moss is among the most knowledgeable and balanced researchers of integrative cancer therapies. The cost of his Moss Reports is not negligible, but many patients find them of considerable value. Moss is also available for consultations.
• Harvard Health Publishing: Should you be taking an omega-3 supplement?
• Linus Pauling Institute, Oregon State University: Essential Fatty Acids
• Gurdev Parmar and Tina Kaczor: Textbook of Naturopathic Oncology: A Desktop Guide of Integrative Cancer Care. 1st edition
• Dawn Lemanne and Victoria Maizes: Advising Women Undergoing Treatment for Breast Cancer
• Block KI, Block PB, Gyllenhaal C: Integrative Treatment for Colorectal Cancer
• Keith Block and others: A Broad-Spectrum Integrative Design for Cancer Prevention and Therapy
• Raymond Chang, MD: Beyond the Magic Bullet: The Anti-Cancer Cocktail
• Donald I. Abrams, MD, and Andrew T. Weil, MD: Integrative Oncology, 2nd Edition
• Neil McKinney, BSc, ND: Naturopathic Oncology, 3rd Edition
• Ted Schettler, MD, MPH: The Ecology of Breast Cancer: The Promise of Prevention and the Hope for Healing
• Lise Alschuler, ND, FABNO, and Karolyn Gazella: The Definitive Guide to Cancer, 3rd Edition
• Keith I. Block, MD: Life over Cancer: The Block Center Program for Integrative Cancer Treatment
• Lorenzo Cohen and Alison Jefferies: Anticancer Living: Transform Your Life and Health with the Mix of Six
• National Cancer Institute: Office of Cancer Complementary and Alternative Medicine
• Lone Star Medical Group: Natural Alternative Treatments
• Michael Lerner: Choices In Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer

References

1. WebMD. The Facts on Omega-3 Fatty Acids. Viewed December 1, 2017.
2. Linus Pauling Institute. Essential Fatty Acids. Oregon State University. Viewed May 14, 2019.
3. Deng GE, Rausch SM et al. Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e420S-e436S.
4. Deng GE, Rausch SM et al. Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e420S-e436S.
5. van der Meij BS, van Bokhorst-de van der Schueren MA, Langius JA, Brouwer IA, van Leeuwen PA. n-3 PUFAs in cancer, surgery, and critical care: a systematic review on clinical effects, incorporation, and washout of oral or enteral compared with parenteral supplementation. American Journal of Clinical Nutrition. 2011 Nov;94(5):1248-65.
6. Fabian CJ, Kimler BF, Hursting SD. Omega-3 fatty acids for breast cancer prevention and survivorship. Breast Cancer Research. 2015 May 4;17:62
7. Patterson RE, Flatt SW et al. Marine fatty acid intake is associated with breast cancer prognosis. Journal of Nutrition. 2011 Feb;141(2):201-6.
8. Bougnoux P, Hajjaji N et al. Improving outcome of chemotherapy of metastatic breast cancer by docosahexaenoic acid: a phase II trial. British Journal of Cancer. 2009 Dec 15;101(12):1978-85.
9. Volpato M, Hull MA. Omega-3 polyunsaturated fatty acids as adjuvant therapy of colorectal cancer. Cancer Metastasis Reviews. 2018 Sep;37(2-3):545-555.
10. Song M, Ou FS et al. Marine omega-3 fatty acid intake and survival of stage III colon cancer according to tumor molecular markers in NCCTG Phase III trial N0147 (Alliance). International Journal of Cancer. 2019 Jul 15;145(2):380-389.
11. Adiamah A, Skořepa P, Weimann A, Lobo DN. The impact of preoperative immune modulating nutrition on outcomes in patients undergoing surgery for gastrointestinal cancer: a systematic review and meta-analysis. Annals of Surgery. 2019 Feb 26.
12. de Aguiar Pastore Silva J, Emilia de Souza Fabre M, Waitzberg DL. Omega-3 supplements for patients in chemotherapy and/or radiotherapy: a systematic review. Clinical Nutrition. 2015 Jun;34(3):359-66.
13. Cheng J, Ogawa K et al. Increased intake of n-3 polyunsaturated fatty acids elevates the level of apoptosis in the normal sigmoid colon of patients polypectomized for adenomas/tumors. Cancer Letters. 2003 Apr 10;193(1):17-24.
14. Cockbain AJ, Volpato M et al. Anticolorectal cancer activity of the omega-3 polyunsaturated fatty acid eicosapentaenoic acid. Gut. 2014 Nov;63(11):1760-8.
15. Cockbain AJ, Volpato M et al. Anticolorectal cancer activity of the omega-3 polyunsaturated fatty acid eicosapentaenoic acid. Gut. 2014 Nov;63(11):1760-8.
16. Courtney ED, Matthews S et al. Eicosapentaenoic acid (EPA) reduces crypt cell proliferation and increases apoptosis in normal colonic mucosa in subjects with a history of colorectal adenomas. International Journal of Colorectal Disease. 2007 Jul;22(7):765-76.
17. Abrams DI. An integrative approach to prostate cancer. Journal of Alternative and Complementary Medicine. 2018 Sep/Oct;24(9-10):872-880.
18. Aronson WJ , Kobayashi N et al. Phase II prospective randomized trial of a low-fat diet with fish oil supplementation in men undergoing radical prostatectomy. Cancer Prevention Research (Phila). 2011 Dec;4(12):2062-71.
19. Aucoin M, Cooley K et al. Fish-derived omega-3 fatty acids and prostate cancer: a systematic review. Integrative Cancer Therapies. 2017 Mar;16(1):32-62.
20. Serna-Thomé G, Castro-Eguiluz D et al. Use of functional foods and oral supplements as adjuvants in cancer treatment. Revista de Investigación Clínica. 2018;70(3):136-146.
21. VanderSluis L, Mazurak VC, Damaraju S, Field CJ. Determination of the relative efficacy of eicosapentaenoic acid and docosahexaenoic acid for anti-cancer effects in human breast cancer models. International Journal of Moleculat Sciences. 2017 Dec 4;18(12). pii: E2607.
22. Tanaka A, Yamamoto A et al. Polyunsaturated fatty acids induce ovarian cancer cell death through ROS-dependent MAP kinase activation. Biochemical and Biophysical Research Communications. 2017 Nov 4;493(1):468-473.
23. Hopkins MM, Meier KE. Free fatty acid receptor (FFAR) agonists inhibit proliferation of human ovarian cancer cells. Prostaglandins, Leukotrienes and Essential Fatty Acids. 2017 Jul;122:24-29.
24. Wan XH, Fu X, Ababaikeli G. Docosahexaenoic acid induces growth suppression on epithelial ovarian cancer cells more effectively than eicosapentaenoic acid. Nutrition and Cancer. 2016;68(2):320-7.
25. Khadge S, Sharp JG et al. Immune regulation and anti-cancer activity by lipid inflammatory mediators. International Immunopharmacology. 2018 Dec;65:580-592.
26. Haberka M, Mizia-Stec K et al. Effects of n-3 polyunsaturated fatty acids on depressive symptoms, anxiety and emotional state in patients with acute myocardial infarction. Pharmacological Reports. 2013;65(1):59-68.
27. Kiecolt-Glaser JK, Belury MA, Andridge R, Malarkey WB, Glaser R. Omega-3 supplementation lowers inflammation and anxiety in medical students: a randomized controlled trial. Brain, Behavior and Immunity. 2011 Nov;25(8):1725-34.
28. Buydens-Branchey L, Branchey M, Hibbeln JR. Associations between increases in plasma n-3 polyunsaturated fatty acids following supplementation and decreases in anger and anxiety in substance abusers. Progress in Neuropsychopharmacology & Biolological Psychiatry. 2008 Feb 15;32(2):568-75.
29. Fux M, Benjamin J, Nemets B. A placebo-controlled cross-over trial of adjunctive EPA in OCD. Journal of Psychiatric Research. 2004 May-Jun;38(3):323-5. 
30. McCabe D, Lisy K, Lockwood C, Colbeck M. The impact of essential fatty acid, B vitamins, vitamin C, magnesium and zinc supplementation on stress levels in women: a systematic review. JBI Database of Systematic Reviews and Implementation Reports. 2017 Feb;15(2):402-453.
31. Sohrabi N, Kashanian M, Ghafoori SS, Malakouti SK. Evaluation of the effect of omega-3 fatty acids in the treatment of premenstrual syndrome: “a pilot trial”. Complementary Therapies in Medicine. 2013 Jun;21(3):141-6.
32. Yehuda S, Rabinovitz S, Mostofsky DI. Mixture of essential fatty acids lowers test anxiety. Nutritional Neuroscience. 2005 Aug;8(4):265-7.
33. Deng GE, Frenkel M et al. Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals. Journal of the Society for Integrative Oncology. 2009 Summer;7(3):85-120.
34. de Aguiar Pastore Silva J, de Souza Fabre ME, Waitzberg DL. Omega-3 supplements for patients in chemotherapy and/or radiotherapy: a systematic review. Clinical Nutrition. 2015 Jun;34(3):359-66.
35. Trabal J, Leyes P, Forga M, Maurel J. Potential usefulness of an EPA-enriched nutritional supplement on chemotherapy tolerability in cancer patients without overt malnutrition. Nutricion Hospitalaria. 2010 Sep-Oct;25(5):736-40.
36. Silva Jde A, Trindade EB et al. Fish oil supplement alters markers of inflammatory and nutritional status in colorectal cancer patients. Nutrition and Cancer. 2012;64(2):267-73.
37. van der Meij BS, van Bokhorst-de van der Schueren MA, Langius JA, Brouwer IA, van Leeuwen PA. n-3 PUFAs in cancer, surgery, and critical care: a systematic review on clinical effects, incorporation, and washout of oral or enteral compared with parenteral supplementation. American Journal of Clinical Nutrition. 2011 Nov;94(5):1248-65.
38. Lavriv DS, Neves PM, Ravasco P. Should omega-3 fatty acids be used for adjuvant treatment of cancer cachexia? Clinical Nutrition ESPEN. 2018 Jun;25:18-25.
39. Ewaschuk JB, Almasud A, Mazurak VC. Role of n-3 fatty acids in muscle loss and myosteatosis. Applied Physiology, Nutrition, and Metabolism. 2014 Jun;39(6):654-62.
40. Read JA, Beale PJ et al. Nutrition intervention using an eicosapentaenoic acid (EPA)-containing supplement in patients with advanced colorectal cancer. Effects on nutritional and inflammatory status: a phase II trial. Supportive Care in Cancer. 2007 Mar;15(3):301-7.
41. Bonatto SJ, Oliveira HH et al. Fish oil supplementation improves neutrophil function during cancer chemotherapy. Lipids. 2012 Apr;47(4):383-9.
42. de Aguiar Pastore Silva J, Emilia de Souza Fabre M, Waitzberg DL. Omega-3 supplements for patients in chemotherapy and/or radiotherapy: a systematic review. Clinical Nutrition. 2015 Jun;34(3):359-66.
43. Pappalardo G, Almeida A, Ravasco P. Eicosapentaenoic acid in cancer improves body composition and modulates metabolism. Nutrition. 2015 Apr;31(4):549-55.
44. Mantovani G, Macciò A et al. Randomized phase III clinical trial of five different arms of treatment in 332 patients with cancer cachexia. Oncologist. 2010;15(2):200-11.
45. Golkhalkhali B, Rajandram R et al. Strain-specific probiotic (microbial cell preparation) and omega-3 fatty acid in modulating quality of life and inflammatory markers in colorectal cancer patients: a randomized controlled trial. Asia-Pacific Journal of Clinical Oncology. 2018 Jun;14(3):179-191.
46. Guu TW, Mischoulon D et al. International Society for Nutritional Psychiatry research practice guidelines for omega-3 fatty acids in the treatment of major depressive disorder. Psychotherapy and Psychosomatics. 2019;88(5):263-273.
47. Sohrabi N, Kashanian M, Ghafoori SS, Malakouti SK. Evaluation of the effect of omega-3 fatty acids in the treatment of premenstrual syndrome: “a pilot trial”. Complementary Therapies in Medicine. 2013 Jun;21(3):141-6.
48. Haberka M, Mizia-Stec K et al. Effects of n-3 polyunsaturated fatty acids on depressive symptoms, anxiety and emotional state in patients with acute myocardial infarction. Pharmacological Reports. 2013;65(1):59-68. 
49. Pereira PTVT, Reis AD et al. Dietary supplements and fatigue in patients with breast cancer: a systematic review. Breast Cancer Research and Treatment. 2018 Oct;171(3):515-526.
50. Mantovani G, Macciò A et al. Randomized phase III clinical trial of five different arms of treatment in 332 patients with cancer cachexia. Oncologist. 2010;15(2):200-11.
51. Golkhalkhali B, Rajandram R et al. Strain-specific probiotic (microbial cell preparation) and omega-3 fatty acid in modulating quality of life and inflammatory markers in colorectal cancer patients: a randomized controlled trial. Asia-Pacific Journal of Clinical Oncology. 2018 Jun;14(3):179-191.
52. Golkhalkhali B, Rajandram R et al. Strain-specific probiotic (microbial cell preparation) and omega-3 fatty acid in modulating quality of life and inflammatory markers in colorectal cancer patients: a randomized controlled trial. Asia-Pacific Journal of Clinical Oncology. 2018 Jun;14(3):179-191.
53. Golkhalkhali B, Rajandram R et al. Strain-specific probiotic (microbial cell preparation) and omega-3 fatty acid in modulating quality of life and inflammatory markers in colorectal cancer patients: a randomized controlled trial. Asia-Pacific Journal of Clinical Oncology. 2018 Jun;14(3):179-191.
54. Ghoreishi Z, Esfahani A et al. Omega-3 fatty acids are protective against paclitaxel-induced peripheral neuropathy: a randomized double-blind placebo controlled trial. BMC Cancer. 2012 Aug 15;12:355.
55. de Aguiar Pastore Silva J, de Souza Fabre ME, Waitzberg DL. Omega-3 supplements for patients in chemotherapy and/or radiotherapy: a systematic review. Clinical Nutrition. 2015 Jun;34(3):359-66.
56. Schloss JM, Colosimo M, Airey C, Masci PP, Linnane AW, Vitetta L. Nutraceuticals and chemotherapy induced peripheral neuropathy (CIPN): a systematic review [published correction appears in Clinical Nutrition. 2015 Feb;34(1):167]. Clinical Nutrition. 2013;32(6):888–893.
57. Giles GE, Mahoney CR et al. Omega-3 fatty acids and stress-induced changes to mood and cognition in healthy individuals. Pharmacology Biochemistry and Behavior. 2015 May;132:10-19.
58. Barbadoro P, Annino I et al. Fish oil supplementation reduces cortisol basal levels and perceived stress: a randomized, placebo-controlled trial in abstinent alcoholics. Molecular Nutrition & Food Research. 2013 Jun;57(6):1110-4.
59. Bonatto SJ, Oliveira HH et al. Fish oil supplementation improves neutrophil function during cancer chemotherapy. Lipids. 2012 Apr;47(4):383-9.
60. de la Rosa Oliva F, Meneses García A et al. Effects of omega-3 fatty acids supplementation on neoadjuvant chemotherapy-induced toxicity in patients with locally advanced breast cancer: a randomized, controlled, double-blinded clinical trial. Nutricion Hospitalaria. 2019 Aug 26;36(4):769-776.
61. Hutchins-Wiese HL, Picho K et al. High-dose eicosapentaenoic acid and docosahexaenoic acid supplementation reduces bone resorption in postmenopausal breast cancer survivors on aromatase inhibitors: a pilot study.
62. Nutrition and Cancer. 2014;66(1):68-76.
63. Xie H, Chang YN. Omega-3 polyunsaturated fatty acids in the prevention of postoperative complications in colorectal cancer: a meta-analysis. OncoTargets and Therapy. 2016 Dec 9;9:7435-7443.
64. Sorensen LS, Thorlacius-Ussing O et al. Randomized clinical trial of perioperative omega-3 fatty acid supplements in elective colorectal cancer surgery. British Journal of Surgery. 2014 Jan;101(2):33-42.
65. Golkhalkhali B, Rajandram R et al. Strain-specific probiotic (microbial cell preparation) and omega-3 fatty acid in modulating quality of life and inflammatory markers in colorectal cancer patients: a randomized controlled trial. Asia-Pacific Journal of Clinical Oncology. 2018 Jun;14(3):179-191.
66. van der Meij BS, van Bokhorst-de van der Schueren MA, Langius JA, Brouwer IA, van Leeuwen PA. n-3 PUFAs in cancer, surgery, and critical care: a systematic review on clinical effects, incorporation, and washout of oral or enteral compared with parenteral supplementation. American Journal of Clinical Nutrition. 2011 Nov;94(5):1248-65.
67. Soldati L, Di Renzo L et al. The influence of diet on anti-cancer immune responsiveness. Journal of Translational Medicine. 2018 Mar 20;16(1):75; Adiamah A, Skořepa P, Weimann A, Lobo DN. The impact of preoperative immune modulating nutrition on outcomes in patients undergoing surgery for gastrointestinal cancer: a systematic review and meta-analysis. Annals of Surgery. 2019 Feb 26.
68. Serna-Thomé G, Castro-Eguiluz D et al. Use of functional foods and oral supplements as adjuvants in cancer treatment. Revista de Investigacion Clinica. 2018;70(3):136-146.
69. Zárate R, El Jaber-Vazdekis N, Tejera N, Pérez JA, Rodríguez C. Significance of long chain polyunsaturated fatty acids in human health. Clinical and Translational Medicine. 2017 Dec;6(1):25.
70. Fabian CJ, Kimler BF, Hursting SD. Omega-3 fatty acids for breast cancer prevention and survivorship. Breast Cancer Research. 2015 May 4;17:62.
71. Zheng JS, Hu XJ, Zhao YM, Yang J, Li D. Intake of fish and marine n-3 polyunsaturated fatty acids and risk of breast cancer: meta-analysis of data from 21 independent prospective cohort studies. BMJ. 2013 Jun 27;346:f3706.
72. Patterson RE, Flatt SW et al. Marine fatty acid intake is associated with breast cancer prognosis. Journal of Nutrition. 2011 Feb;141(2):201-6.
73. Fabian CJ, Kimler BF, Hursting SD. Omega-3 fatty acids for breast cancer prevention and survivorship. Breast Cancer Research. 2015 May 4;17:62.
74. Patterson RE, Flatt SW et al. Marine fatty acid intake is associated with breast cancer prognosis. Journal of Nutrition. 2011 Feb;141(2):201-6.
75. Zárate R, El Jaber-Vazdekis N, Tejera N, Pérez JA, Rodríguez C. Significance of long chain polyunsaturated fatty acids in human health. Clinical and Translational Medicine. 2017 Dec;6(1):25.
76. Song M, Chan AT. Environmental factors, gut microbiota, and colorectal cancer prevention. Clinical Gastroenterology and Hepatology. 2019 Jan;17(2):275-289; Hall MN, Chavarro JE, Lee IM, Willett WC, Ma J. A 22-year prospective study of fish, n-3 fatty acid intake, and colorectal cancer risk in men. Cancer Epidemiology, Biomarkers & Prevention. 2008 May;17(5):1136-43.
77. Kim S, Sandler DP, Galanko J, Martin C, Sandler RS. Intake of polyunsaturated fatty acids and distal large bowel cancer risk in whites and African Americans. American Journal of Epidemiology. 2010 May 1;171(9):969-79; Satia JA, Littman A, Slatore CG, Galanko JA, White E.Associations of herbal and specialty supplements with lung and colorectal cancer risk in the VITamins and Lifestyle study. Cancer Epidemiology, Biomarkers & Prevention. 2009 May;18(5):1419-28.
78. Kantor ED, Lampe JW, Peters U, Vaughan TL, White E. Long-chain omega-3 polyunsaturated fatty acid intake and risk of colorectal cancer. Nutrition and Cancer. 2014;66(4):716-27.
79. Kim S, Sandler DP, Galanko J, Martin C, Sandler RS. Intake of polyunsaturated fatty acids and distal large bowel cancer risk in whites and African Americans. American Journal of Epidemiology. 2010 May 1;171(9):969-79.
80. Katona BW, Weiss JM. Chemoprevention of colorectal cancer. Gastroenterology. 2020;158(2):368–388.
81. Zárate R, El Jaber-Vazdekis N, Tejera N, Pérez JA, Rodríguez C. Significance of long chain polyunsaturated fatty acids in human health. Clinical and Translational Medicine. 2017 Dec;6(1):25.
82. Song M, Chan AT. Environmental factors, gut microbiota, and colorectal cancer prevention. Clinical Gastroenterology and Hepatology. 2019 Jan;17(2):275-289.
83. Hull MA, Sprange K et al. Eicosapentaenoic acid and aspirin, alone and in combination, for the prevention of colorectal adenomas (seAFOod Polyp Prevention trial): a multicentre, randomised, double-blind, placebo-controlled, 2 × 2 factorial trial. Lancet. 2018 Dec 15;392(10164):2583-2594.
84. Zárate R, El Jaber-Vazdekis N, Tejera N, Pérez JA, Rodríguez C. Significance of long chain polyunsaturated fatty acids in human health. Clinical and Translational Medicine. 2017 Dec;6(1):25.
85. Satia JA, Littman A, Slatore CG, Galanko JA, White E.Associations of herbal and specialty supplements with lung and colorectal cancer risk in the VITamins and Lifestyle study. Cancer Epidemiology, Biomarkers & Prevention. 2009 May;18(5):1419-28.
86. Aucoin M, Cooley K et al. Fish-derived omega-3 fatty acids and prostate cancer: a systematic review. Integrative Cancer Therapies. 2017 Mar;16(1):32-62.
87. Zárate R, El Jaber-Vazdekis N, Tejera N, Pérez JA, Rodríguez C. Significance of long chain polyunsaturated fatty acids in human health. Clinical and Translational Medicine. 2017 Dec;6(1):25.
88. Serna-Thomé G, Castro-Eguiluz D et al. Use of functional foods and oral supplements as adjuvants in cancer treatment. Revista de Investigacion Clinica. 2018;70(3):136-146.
89. Pappalardo G, Almeida A, Ravasco P. Eicosapentaenoic acid in cancer improves body composition and modulates metabolism. Nutrition. 2015 Apr;31(4):549-55; de Aguiar Pastore Silva J, Emilia de Souza Fabre M, Waitzberg DL. Omega-3 supplements for patients in chemotherapy and/or radiotherapy: a systematic review. Clinical Nutrition. 2015 Jun;34(3):359-66.
90. Sorensen LS, Thorlacius-Ussing O et al. Effects of perioperative supplementation with omega-3 fatty acids on leukotriene B₄ and leukotriene B₅ production by stimulated neutrophils in patients with colorectal cancer: a randomized, placebo-controlled intervention trial. Nutrients. 2014 Sep 29;6(10):4043-57; Silva Jde A, Trindade EB et al. Fish oil supplement alters markers of inflammatory and nutritional status in colorectal cancer patients. Nutrition and Cancer. 2012;64(2):267-73; Xie H, Chang YN. Omega-3 polyunsaturated fatty acids in the prevention of postoperative complications in colorectal cancer: a meta-analysis. OncoTargets and Therapy. 2016 Dec 9;9:7435-7443; Golkhalkhali B, Rajandram R et al. Strain-specific probiotic (microbial cell preparation) and omega-3 fatty acid in modulating quality of life and inflammatory markers in colorectal cancer patients: a randomized controlled trial. Asia-Pacific Journal of Clinical Oncology. 2018 Jun;14(3):179-191; Aucoin M, Cooley K et al. Fish-derived omega-3 fatty acids and prostate cancer: a systematic review. Integrative Cancer Therapies. 2017 Mar;16(1):32-62.
91. Mocellin MC, Camargo CQ, Nunes EA, et al. A systematic review and meta-analysis of the n-3 polyunsaturated fatty acids effects on inflammatory markers in colorectal cancer. Clinical Nutrition. 2016;35:359–369.
92. Liang B, Wang S, Impact of postoperative omega-3 fatty acid-supplemented parenteral nutrition on clinical outcomes and immunomodulations in colorectal cancer patients. World Journal of Gastroenterology. 2008 Apr 21;14(15):2434-9.
93. Kiecolt-Glaser JK, Belury MA, Andridge R, Malarkey WB, Glaser R. Omega-3 supplementation lowers inflammation and anxiety in medical students: a randomized controlled trial. Brain, Behavior and Immunity. 2011 Nov;25(8):1725-34.
94. Soldati L, Di Renzo L et al. The influence of diet on anti-cancer immune responsiveness. Journal of Translational Medicine. 2018 Mar 20;16(1):75; Adiamah A, Skořepa P, Weimann A, Lobo DN. The impact of preoperative immune modulating nutrition on outcomes in patients undergoing surgery for gastrointestinal cancer: a systematic review and meta-analysis. Annals of Surgery. 2019 Feb 26.
95. Polokowski AR, Shakil H, Carmichael CL, Reigada LC. Omega-3 fatty acids and anxiety: a systematic review of the possible mechanisms at play. Nutritional Neuroscience. 2020 Jul;23(7):494-504. 
96. Daenen LG, Cirkel GA et al. Increased plasma levels of chemoresistance-inducing fatty acid 16:4(n-3) after consumption of fish and fish oil. JAMA Oncology. 2015 Jun;1(3):350-8.
97. Daenen LG, Cirkel GA et al. Increased plasma levels of chemoresistance-inducing fatty acid 16:4(n-3) after consumption of fish and fish oil. JAMA Oncology. 2015 Jun;1(3):350-8.
98. Abrams D. An integrative approach to prostate cancer. The Journal of Alternative and Complementary Medicine. 2018 Sep/Oct;24(9-10):872-880.
99. Alschuler LN, Gazella KA. The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing. Berkeley, California: Celestial Arts. 2010; Alschuler LN, Gazella KA. The Definitive Guide to Thriving after Cancer: A Five-Step Integrative Plan to Reduce the Risk of Recurrence and Build Lifelong Health. Berkeley, California: Ten Speed Press. 2013.
100. Block KI. Life over Cancer: The Block Center Program for Integrative Cancer Treatment. New York: Bantam Dell. 2009.
101. Chang R. Beyond the Magic Bullet: The Anti-Cancer Cocktail. New York: Square One Publishers. 2012.
102. Lemole G, Mehta P, McKee D. After Cancer Care: The Definitive Self-Care Guide to Getting and Staying Well for Patients with Cancer. New York, New York: Rodale, Inc. 2015.
103. MacDonald B. The Breast Cancer Companion: A Complementary Care Manual: Third Edition. (self-published, Amazon, 2016).
104. McKinney N. Naturopathic Oncology, 3rd Edition. Victoria, BC, Canada: Liaison Press. 2016.
105. Parmar G, Kaczor T. Textbook of Naturopathic Oncology: A Desktop Guide of Integrative Cancer Care. 1st edition. Canada: Medicatrix Holdings Ltd. 2020.