The Use of Plants' Natural Products in Breast Cancer: Have We Already Found the New Anticancer Drug?

*Isadora de Fátima Braga Magalhães, Kátia da Silva Calabrese, Ana Letícia Marinho Figueirêdo, Ana Lucia Abreu-Silva and Fernando Almeida-Souza*

## **Abstract**

The importance of a new anticancer drug for breast cancer is well established. Natural compounds that can prevent this disease or be used as an adjuvant treatment associated with conventional drugs could be the solution for this. This chapter is an overview of agents extracted from plants with outstand results in the last six years. Green tea, berberine, thymoquinone and cannabidiol are compounds isolated from medicinal plants. These agents showed action through induction of apoptosis, down regulation of inflammation, epigenetics, hormonal modulation, among other. In vitro effect against cancer cells, in vivo experiments mainly with murine model and clinical trials reassured their efficacy against breast cancer. A protective effect against recurrence cases and chemosensitization to standard drugs was also successful. The use of nanotechnology provided a optimize delivery of these therapeutical molecules. Taken together this information led us to acknowledgement that we do probably have the natural agents for a future adjuvant treatment against breast cancer.

**Keywords:** plants, phytotherapy, breast cancer, green tea, berberine, thymoquinone, cannabidiol, anticancer

## **1. Introduction**

Breast cancer (BC) remains one of the leading causes of death [1] and one of the most common types of malignancies among women worldwide [2]. The conventional treatment includes chemotherapy, hormone therapy, radiotherapy and surgery. Problems such as high recurrence and toxicity to medication are frequent [1]. Due to this, the combination of the conventional treatment with a new approach is the key to a higher degree of success in the therapeutic of this disease.

Complementary therapies are already used among many women who have BC to help dealing with adverse effects or against recurrence. Phytotherapy is one of the most popular adjuvant therapies and a common target for a new BC drug [1]. Plant-derived anticancer therapeutics aim to reduce side effects and increase the sensitivity to chemotherapy and the overall effectiveness of the treatment [3].

Although there is a false believe in the harmlessness of plants, they can cause negative effects and even reduce the therapeutic effects of standard drugs. Therefore, is crucial to understand their correct dosage and potential effects [1].

Over the past decades, many bioactive phytochemicals from medicinal plants have being studied and some of them have remarkable results. Among all these natural compounds, it is natural to ask ourselves: have we found the answer yet? What is the role of plant derived compounds in reducing breast cancer cells and promoting survival and less recurrence among breast cancer patients? This chapter is an overview of agents extracted from plants with outstand results in the last six years. Therefore, can be helpful in trying to answer these questions.

## **2. Green tea**

Tea has become one of the most popular beverages all over the world. The consumption of green tea gained popularity in the last years and is now associated with a different lifestyle. Green tea, *Camellia sinensis* [4], has shown anticancer effect on different types of cancer [5] and apparently possess many chemopreventive qualities in primary breast cancer and recurrence [6].

In the search for different forms that green tea can act as an anticancer agent in BC, hormonal modulation has been considered. Supplementation with decaffeinated green tea extract significantly increases circulating of estradiol in healthy postmenopausal women. The consumption of green tea extract also reduces circulation of cholesterol and LDL-cholesterol [7], and the regular consume seems to facilitate lipid metabolisms in breast cancer survivors [8]. In a study among Chinese women in Hong Kong, drinking green tea was not associated with overall breast cancer risk, which may be masked by the differential effect in pre- and post-menopausal women, due to modified hormone receptor expression [9].

A great potential as a chemo-preventive agent against breast cancer can be attributed to green tea, especially for recurrence [6]. Drinking at least five cups of green tea per week may be associated with decreased breast cancer risk [10].

Tamoxifen is an adjuvant treatment for hormone receptor-positive breast cancer, but drug resistance related to genetic and epigenetic mechanisms is rising to dangerously levels [11]. Tamoxifen has no pharmacokinetic interaction with green tea [12] which can encourage this association.

Green tea high inhibited the proliferation of cell line derived from breast cancer in mouse, named 4TI cells, with upregulation of Casp8, Casp9, Casp3, Casp6, Casp8AP2, Aifm1, Aifm2 and Apopt1 genes [13]. When associated with silicon nanomaterials, this compound has action against breast cancer in vitro and in vivo with inhibition of tumor growth [14].

Catechin, epicatechin, epigallocatechin and epigallocatechin-3-gallate (EGCG) are the four major constituents of green tea [15]. EGCG has demonstrated potential anticancer effects on several preclinical and clinical researches [16].

Epigenetics are non-mutational events that alter the expression of genes [17]. Catechins from green tea, especially EGCG, are be able to modulate epigenetic processes by increasing transcription of tumor suppressor genes through attenuating the effect of DNA methyltransferase 1 (DNMT1) and consequently reversing DNA methylation [18].

The most active anticancer component in green tea is EGCG [19]. EGCC might act on breast cancer cells progression through inhibition of focal adhesion kinase (FAK) signaling pathway [20], by interfering in proteins involved in cell death and survival, DNA replication, recombination and repair [21]. It can also interfere on the expression of genes such as PTEN, CASP3, CASP9 [22] and through inhibition

*The Use of Plants' Natural Products in Breast Cancer: Have We Already Found… DOI: http://dx.doi.org/10.5772/intechopen.96404*

of protein tyrosine phosphatase 1B (PTP1B) activity [23], a protein that plays a crucial role in the development of breast cancer, with higher levels associated with tumor size and lymph node metastasis in patients [24]. EGCG also decreases BC cells with similar results as tamoxifen [22].

A protective effect of EGCG on BC was reaffirmed on several experimental models and different conditions with promising clinical implications for breast cancer prevention and therapy [25].

A lecithin formulation of a caffeine-free green tea catechin extract named green select phytosome (GSP) increased the bioavailability of EGCG on early breast cancer patients who received GSP in 300 mg dose, daily, for 4 weeks prior to surgery [26].

Capsules of green tea with a high dose (843 mg) of EGCG provided during 12 months reduced the percent of mammographic density in younger women similar to tamoxifen. This indicates a possible chemo preventive effect on breast cancer risk, although no effect was detected on older women [27]. The treatment with EGCG can also act through epigenetic by reduction of the expression and activity of DNA methyltransferase and decreasing of methylation of the domain-containing epidermal growth factor-like 2 (2SCUBE2), a tumor suppressor that inhibits BC cells migration and invasion [28].

EGCG and quercetin isolated from green tea and green tea alone had anticarcinogenic effect on estrogen receptor-positive and -negative breast cancer cells [29]. It also showed in vitro and in vivo effect, by inhibiting the growth of 4 T1 tumor and increasing the proportions of CD4+ and CD8+ T cells at tumor sites in mice. EGCG regulated the canonical and non-canonical pathways in myeloid-derived suppressor cells (MDSCs) [30].

The action of polyphenols from green tea on BC cells was mediated by apoptosis thought mitochondrial pathway with induction of DNA fragmentation and activation of caspase-3 and caspase-9 [31].

#### **Figure 1.**

*Green tea and breast cancer. Hormonal modulation. The consumption of green tea causes hormonal modulation through depression of estradiol and cholesterol levels and increase of LDL-cholesterol levels. Epigallocatechin-3-gallate. Epigallocatechin-3-gallate isolated from green tea causes effects in epigenetic by decreasing methylation of tumor suppressors such as epidermal growth factor-like 2 (2SCUBE2); inhibits focal adhesion kinase (FAK) signaling pathway; interferes in the expression of genes such as phosphatase and tensin homolog (PTEN), caspase-3 (CASP3), caspase-9 (CASP9) and protein-tyrosine phosphatase 1B (PTP1B); has protective effect against breast cancer and is effective in murine model by decreasing breast cancer cells 4 T1 and increasing the proportions of CD4+ and CD8+ T cells at tumor sites. Side effects. Hepatotoxicity and gastrointestinal disorders are reported mainly when tea is consumed with an empty stomach. Chemoprevention. Green tea is a chemo-preventive in women causing less recurrence cases and also lower risk of breast cancer when at least 5 cups of tea are consumed per week.*

Matcha green tea (MGT), a special type of green tea with higher concentrations of catechins due to a different preparation [32] inhibits mTOR, stimulates an antioxidant response and interferes in interleukin signaling in BC cells [33].

Some side effects have been associated with green tea such as hepatotoxicity and gastrointestinal disorders, especially if consumed on an empty stomach (**Figure 1**). Although green tea and its main components are not major teratogen, mutagen or carcinogen substances and have a selective cytotoxicity against cancer cells, some caution needs to be taken in pregnant and breast-feeding women due to the lack of information [4]. Between Japanese women, green tea was the most commonly consumed nonalcoholic beverage, and it had no significant associations with breast cancer risk [34].

## **3. Berberine**

Berberine(5,6-dihydro-9,10-dimethoxybenzo[g]-1,3-benzodioxolo[5,6-a] quinolizinium) is an alkaloid with several properties, such as hepatoprotective, immunomodulatory, cardioprotective and antioxidative. Plants containing this compound have been traditionally used in different parts of the world for the treatment of affections in the eyes, inflammatory diseases, dermatitis, wound healing, digestive and respiratory diseases and treatment of neoplasia [35].

A wide variety of different plant species contains berberine (BBR), such as *Coptis chinensis* [36], *Rhizoma coptidis* [37], *Berberis vulgaris* [38], *Arcangelisia flava*, *Berberis aquifolium* and *Berberis aristate*. The genus Berberis contains nearly 550 species [39].

Due to the ability to seize the cell cycle and induce apoptosis of cancer cells, berberine has received considerable research attention [40]. BBR can inhibit tumor growth and metastasis of triple negative breast cancer cells (TNBC) by suppression of transforming growth factor beta 1 (TGF-β1) expression, a multifunctional factor associated with poor prognosis on BC. It also decreased lung metastasis and tumor growth in MDA-MB-231, a cell line originated from an invasive ductal carcinoma, and 4 T1 breast cancer xenograft models [41]. Same effect was detected in tumor growth in MDA-MB-231 nude mouse xenografts, with binding of vasodilator-stimulated phosphoprotein (VASP), related to cell migration and overexpressed in high-motility BC cells [42] and throught caspase-9 pathway [43]. At a 50 mg/kg dose, BBR demonstrated a preventive role in rats with mammary ductal and invasive carcinoma [40].

BBR suppresses breast cancer cells through inhibition of transforming growth factor beta 1 (TGF-β1) expression [41], targeting ephrin-B2 [44], AMPK signaling pathway [45], inhibition of specific activator protein-1 (AP-1) activity [46], triggering to a caspase9-dependent apoptosis [43], affecting mRNA levels of chemokine receptors genes such as C-X-C motif chemokine receptor 1 (CXCR1) and C-X-C motif chemokine receptor 4 (CXCR4) [47] and by inducing nucleolar stress and upregulation of p53, a tumor suppressor gene [48].

The anti-cancer ability of BBR against BC may be partially dependent on the regulation of metadherin [49] and attenuation of inflammation through inhibition of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) activation [50] and reduction of secretion of proinflammatory cytokines such as interleukin-1α (IL-1α), interleukin-1β (IL-1β), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) [51]. BBR also reduces interleukin-8 (IL-8) secretion, which is associated with poor outcomes involving metastasis-free survival and relapse-free [52].

In animals, the inhibition of canine mammary gland carcinoma cells, highlights its potential against the most frequent cause of cancer in female dogs [53].

Salt-inducible kinases 3 (SIK3) belong to the AMPK-related family of kinases, and when highly expressed is associated with poor survival among BC patients. This kinase was significantly inhibited by the combination of emodin and BBR [54].

## *The Use of Plants' Natural Products in Breast Cancer: Have We Already Found… DOI: http://dx.doi.org/10.5772/intechopen.96404*

Another successful combination happened between lapatinib and BBR, and reversed the resistance to lapatinib through downregulating of c-Myc, a gene often expressed in cancer [55]. The association between BBR and doxorubicin increased chemosensitivity to this agent [45] and reverted the resistance by inhibiting autophagy [56].

The combination of theophylline and berberine showed a synergistic antiproliferation effect on MDA-MB-231 cells, with a less necrotic effect and increased apoptotic cell death [57]. A sensibilization of BC cells to the chemotherapeutic drugs cisplatin, camptothecin and methyl methanesulfonate was provide by the association with BBR by a deoxyribonucleic acid (DNA) repair pathway involving XRCC1, a protein involved in the efficient repair of DNA [58].

Berberine and tamoxifen together induced cell growth inhibition more effectively than tamoxifen alone [59] and BBR with evodiamine synergistically induced cell cycle arrest and apoptosis of MCF-7 cells [60], an established breast cancer cell line originated from a pleural effusion of a patient with invasive breast ductal carcinoma.

Synergetic effect between poly (lactic-co-glycolic acid) nanoparticles with doxorubicin conjugate for encapsulation and BBR increased rat half-life and antiproliferative action against BC cells [61]. The encapsulation with citrate-capped silver nanoparticles was also efficient [62].

The association of BBR and exercise, consider an immunotherapy treatment, against BC showed a synergistic effect in vitro and in mice, throught the improvement of the immune system, regulation of intestinal microbial metabolite and activation of apoptosis [36].

Although there are many positive outcomes on the therapy with BBR, a low dose of berberine caused attenuation on chemotherapeutic drugs fluorouracil (5-FU) and camptothecin activities [37] (**Figure 2**). Therefore, some caution needs to be taken in regards to its use.

#### **Figure 2.**

*Berberine and breast cancer. Plants. Many plants can contain berberine, such as Coptis chinensis, Rhizoma coptidis, Berberis vulgaris and Berberis aristate. Mechanism of action. Berberine induces apoptosis of cancer cells; reduces transforming growth factor beta 1 (TGF-*β*1) expression; regulates metadherin; attenuates inflammation by inhibition of nuclear factor kappa B (NF-*κ*B) activation and reduction of interleukins IL-1*α*, IL-1*β*, IL-6, IL-8 and tumor necrosis factor-*α *secretions. Synergetic effect. Between berberine and emodin, lapatinib, doxorubicin, theophylline, tamoxifen, evodiamin, and also with physical exercise. Negative effect. Berberine causes attenuation on chemotherapeutic drugs fluorouracil (5-FU) and camptothecin activities. Nanotechnology. Nanotechnology provides an increased half-life and reduced tumor cells in rats with induced breast cancer.*

## **4. Thymoquinone**

Black cumin seed from *Nigella sativa*, also known as cumin, is used for centuries and it has unsurpassed traditional medicinal value and versatility to treat a wide range of diseases [63]. *N. sativa* is the source of the monoterpene thymoquinone, a compound that can cause anticancer effect in proliferation, migration and invasion in different human cancers including breast cancer lineages [64].

Thymoquinone (TQ ) induces apoptosis through death receptors, inhibits TNBC cell line and also can cause in vivo effects on mouse tumor model [65]. TQ inhibits autophagic activity and expression of Beclin-1 and LC3 in TNBC cells and suppresses pathways related to cell invasion and angiogenesis, including integrin-β1, vascular endothelial growth fator (VEGF), matrix metalloproteinase-2 (MMP-2) and MMP-9, suggesting that TQ may be used to control autophagic activity and oncogenic signaling in TNBC [66]. In silico docking studies confirm the action against TNBC, with thymoquinone down-regulating poly (ADP-ribose) polymerase (PARP) gene expression, docking metastatic, apoptotic and cell proliferation targets [67].

TQ-induced ceramide accumulation and endoplasmic reticulum stress, decreased S1P, C1P and NF-κB, triggered apoptosis in BC cells [68] and also changed the cell cycle progression [69].

The combination between different anticancer drugs can be helpful to reduce dose causing less side effects and reducing multidrug resistance. Synergic effect was detected with a combination of TQ with paclitaxel [65] and also with resveratrol, causing a decrease in tumor size, enhanced apoptosis, decreased VEGF expression, elevated levels of interferon-gama (IFN-γ), angiogenesis inhibition with no toxic effect on liver or kidney [70].

TQ and piperine, another bioactive compound of *N. sativa*, together caused an anticancer action in vitro and in vivo in murine model by angiogenesis inhibition, induction of high degrees of apoptosis and shifting the immune response towards a T helper1 response [71], a similar result to the combination with melatonin [72]. When associated with gemcitabine, TQ caused a better anti-cancer activity via modulation of apoptotic and autophagic action [73].

A combined doxorubicin thymoquinone-loaded with aragonite calcium carbonate nanoparticle showed higher efficacy against BC cells at lower dose of doxorubicin and TQ [74]. In a clinical trial, combination between tamoxifen and TQ had a better effect than each of these drugs alone on patients with BC [2].

TQ and black cumin seed oil anticancer effect in BC in female rats induced by 7,12-dimethylbenz[a]anthracene (DMBA), caused alteration on rates of tumor markers such as malondialdehyde (MDA), lactate dehydrogenase (LDH), alkaline phosphatase (ALP) and aspartate aminotransferase (AST) and decrease of the expression of Brca1, Brca2, Id-1 and P53 mutations which highlights a protective effective against BC [63]. In xenograft tumors in mice, TQ inhibited metastasis through enhanced promotion of DNA methylation of the TWIST1 gene [75]. A reduced in drug resistance, anti-migratory potency and tumor size in ex-ovo xenograft was possible with TQ associated with Emodin [76].

Using a metastasis breast cancer mouse model, TQ treatment suppressed multiple metastases in bone, brain, lungs. This effect was attributed to down-regulation of NF-κB and chemokine receptor type 4 (CXCR4) expression, an indicator of poor prognosis in patients (**Figure 3**) [77].

Agents than can make a compound more available and deliver a more efficient effect are being searched. The encapsulation of TQ in nanoparticles improved the bioavailability of this compound [78], and a nanostructured lipid carrier enhanced the therapeutic qualities of TQ by increasing the survival rate of mice [79]. Same

*The Use of Plants' Natural Products in Breast Cancer: Have We Already Found… DOI: http://dx.doi.org/10.5772/intechopen.96404*

#### **Figure 3.**

*Thymoquinone and breast cancer. Combination. The combination of thymoquinone (TQ ) and paclitaxel, piperine, gemcitabine and melatonin have synergic effects including reduction of tumor size and angiogenesis, increasing of cancer cells apoptosis and shifting of the immune response towards a T helper1 response. Effects. The effects in breast cancer includes induction of apoptosis; antiproliferative effect in triple negative breast cancer (TNBC) cells; anticancer effects in silico experiments by downregulation of poly (ADP-ribose) polymerase (PARP) gene expression; suppression of metastases in bone, brain and lungs, down-regulation of nuclear factor kappa B (NF-*κ*B), chemokine receptor type 4 (CXCR4) and Brca1, Brca2, id-1 and P53 mutations expression. Bioavailability. The use of nanothenology increased the bioavailability of thymoquinone. Beneficial effects. Overall action against proliferation, migration and invasion of breast cancer cells was confirmed.*

effects were obtained with low-molecular-weight chitosan-grafted lipid nanocapsules to co-delivery docetaxel and TQ [80], cubosomal nanoparticles used to encapsulate TQ [81] and cabazitaxel and TQ co-loaded lipospheres [82].

## **5. Cannabidiol**

Cannabidiol (CBD) is the main non-psychoactive component of *Cannabis sativa* [83]. Although researches related to cannabis derivates need to face a lot of misunderstanding due to association with psychoactive effects and recreation [84], cannabidiol has proven to stimulate apoptosis pathways and inhibit metastasis, angiogenesis and proliferation of different cancer cells [85].

Cannabidiol can act in cancer cells in a receptor-independent way but also thought CB-receptors such as CB1-R, with moderated expression in BC, and CB2-R with high expression related to tumor aggressiveness. Breast cancer positive for the protein human epidermal growth factor receptor 2 (HER2+), a protein that promotes cancer cells growth, when associated with expression of a cannabinoid receptor (CB2) is associated to poor patient prognosis, therefore can be used as a biomarker with prognostic value [86].

Cannabidiol has an antiproliferative effect against aggressive subtype of BC cells, and also inhibits tumor growth in murine model by interfering in the recruitment of macrophages [83]. The anti-cancer effects of CBD on BC cells are related to regulatory effects on the biogenesis of exosomes and microvesicles released by cells and involved in intercellular communication [87] and by inducing apoptosis with down-regulation of mammalian target of rapamycin (mTOR) and cyclin D1 and up-regulation of peroxisome proliferator-activated receptor gamma (PPARγ) protein expression [88]. CBD also blocks and reverts the effect of IL-1β involved in the change to a malignant phenotype through epithelialmesenchymal transition [89].

Mice treated with a combination of CBD and doxorubicin had reduced tumor weight and increased apoptosis than the animals treated with CBD or doxorubicin alone [90]. The co-administration of CBD in solution and paclitaxel or doxorubicin showed a synergistic effect, and cannabidiol-loaded microparticles extended release of this compound, causing an optimized action [91]. The cannabinoid combination of tetrahydrocannabinol, cannabigerol, cannabinol and cannabidiol induced apoptosis in BC cell line in a reduced dose with good selectivity, killing BC cells with minimized harmful effects to normal cells [92].

In low dose of 40 mg/day, the treatment with CBD inhibited cytochrome P450 3A4 and P450 2D6, enzymes with important role in cancer treatment, and increased endoxifen levels in a woman with a history of bilateral breast carcinoma in remission [93]. Typical cannabinoids and abnormal cannabidiol had antiproliferative effects on paclitaxel-resistant BC cells and they both reduced tumor growth in zebrafish xenograft model [94].

A botanical drug preparation was more potent than delta-9-tetrahydrocannabinol, a pure compound, as an anticancer agent in cell culture and animal model, which highlights the potential of standardized cannabis drug preparations to manage BC [95]. Synthetic cannabidiol was analyzed in 119 cancer patients over a four-year period and it led to a reduced circulation of tumor cells or reduced tumor size with no side-effects [96].

A precursor of cannabidiol, cannabidiol acid, downregulates the protooncogene c-fos and the cyclooxygenase-2 (COX-2) signaling, an anti-inflammatory response that can be linked to the anticancer activity [97].

An effective result in reducing symptoms associated with tumors such as anorexia, nausea and neuropathic pain, and also to decelerate tumor progression in earlier breast cancer cases was attributed to cannabidiol (**Figure 4**) [98].

#### **Figure 4.**

*Cannabidiol and breast cancer. Bilateral breast carcinoma. Treatment with cannabidiol inhibited cytochrome P450 3A4 and P450 2D6 and increased endoxifen levels in a woman with a history of bilateral breast carcinoma. Reduction of symptoms related to tumors. Cannabidiol reduces symptoms associated with tumors such as anorexia, nausea and neuropathic pain. Outcomes. Cannabidiol regulates intercellular communication; induces apoptosis of breast cancer cells through down-regulation of mammalian target of rapamycin (mTOR) and cyclin D1 and up-regulation of peroxisome proliferator-activated receptor gamma (PPAR*γ*) protein expression; blocks the effect of IL-1*β*; reduces tumor size and tumor progression; cannabinoid receptor can be used as biomarker with prognostic value. Cannabidiol acid. Demonstrated anti-inflammatory response by proto-oncogene c-fos and cyclooxygenase-2 (COX-2) signaling downregulation. Synergetic effects. The combination between cannabidiol with doxorubicin or paclitaxel increased the anticancer action.*

*The Use of Plants' Natural Products in Breast Cancer: Have We Already Found… DOI: http://dx.doi.org/10.5772/intechopen.96404*

## **6. Conclusions**

The need for a more efficient therapeutic to treat breast cancer is imminent, due to side effects and chemoresistance associated with the current treatment. In these chapter we demonstrated the potential of natural compounds to be used as a new anticancer drug against breast cancer.

A natural compound that can protect against one of the most lethal cancers can save thousands of women's lives, and green tea, berberine, thymoquinone and cannabidiol all showed this capability at different experiments.

In vitro action through multiple pathways involving apoptosis and epigenetics, and in vivo experiments, mainly with mouse model, showed decrease of tumor size and angiogenesis. A stimulation of an anti-inflammatory response with cannabidiol, thymoquinone or berberine treatment reveled another link to an anticancer response.

These agents promoted chemo sensitization, making breast cancer cells more sensible to the effect of drugs used in conventional treatment. A synergistic effect with other natural products or standard drugs such as tamoxifen, paclitaxel, doxorubicin and cisplatin were able to reaffirm the possibility of these combination to reduce dose and side effects.

Antiproliferative action against triple-negative breast cancer cells emphasizes the potential of these therapeutic molecules to treat aggressive and difficult cases of breast cancer. Several clinical trials including a large period of time demonstrated a protective and preventive role of these phytocompounds, with almost no side-effects.

Nanotechnology was often used to increase the bioavailability, create a targetoriented delivery and also to provide an effective lower dose of phytomedicine against breast cancer.

Taken together this information led us to acknowledgement that we do probably have the natural agents for a future adjuvant treatment against breast cancer.

## **Acknowledgements**

This research was funded by the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aper feiçoamento de Pessoal de Nível Superior do Brazil—CAPES) [grant number Finance Code 001]. Fernando Almeida-Souza is postdoctoral researcher fellow of CAPES [grant number 88887.363006/2019-2100]. Dra. Ana Lucia Abreu-Silva is research productivity fellow of National Scientific and Technological Development Council (Conselho Nacional de Desenvolvimento Científico e Tecnológico—CNPq) [grant number 309885/2017-5].

## **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Isadora de Fátima Braga Magalhães1,2\*, Kátia da Silva Calabrese3 , Ana Letícia Marinho Figueirêdo2 , Ana Lucia Abreu-Silva2 and Fernando Almeida-Souza2,3

1 Federal Fluminense University, Niterói, Brazil

2 State University of Maranhão, São Luís, Brazil

3 Oswaldo Cruz Institute, Rio de Janeiro, Brazil

\*Address all correspondence to: isadoradefatimamagalhaes@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The Use of Plants' Natural Products in Breast Cancer: Have We Already Found… DOI: http://dx.doi.org/10.5772/intechopen.96404*

## **References**

[1] Lopes CM, Dourado A, Oliveira R. Phytotherapy and nutritional supplements on breast cancer. BioMed Research International. 2017;7207983. DOI: 10.1155/2017/7207983

[2] Elrashedy M, Kabel A, Omar M. Ameliorative potential of tamoxifen/ thymoquinone combination in patients with breast cancer: a biochemical and immunohistochemical study. Journal of Cancer Science and Research.2016;1: 102.DOI: 10.4172/2576-1447.1000102

[3] GospodinovaZI, Zupkó I, Bózsity N, Manova VI, Georgieva MS, Todinova SJ, Taneva SG, Ocsovszki I, Krasteva ME. *Cotinus coggygria* Scop. induces cell cycle arrest, apoptosis, genotoxic effects, thermodynamic and epigenetic events in MCF7 breast cancer cells. Zeitschrift für Naturforschung C: A Journal of Biosciences. 2020.DOI: 10.1515/ znc-2020-0087

[4] Bedrood Z, Rameshrad M, Hosseinzadeh H. Toxicological effects of Camellia sinensis (green tea): A review. Phytotherapy Research. 2018;32: 1163- 1180.DOI: 10.1002/ptr.6063

[5] Saeed M, Naveed M, Arif M, Kakar MU, Manzoor R, Abd El-Hack ME, Alagawany M, Tiwari R, Khandia R, Munjal A, Karthik K, Dhama K, Iqbal HMN, Dadar M, Sun C. Green tea (*Camellia sinensis*) and l-theanine: Medicinal values and beneficial applications in humans-A comprehensive review. Biomedicine & Pharmacotherapy. 2017; 95:1260-1275. DOI: 10.1016/j.biopha.2017.09.024

[6] Gianfredi V, Nucci D, Abalsamo A, Acito M, Villarini M, Moretti M, Realdon, S. Green tea consumption and risk of breast cancer and recurrence-a systematic review and meta-analysis of observational studies. Nutrients.2018; 10:1886. DOI:10.3390/nu10121886

[7] Samavat H, Newman AR, Wang R, Yuan JM, Wu AH, Kurzer MS. Effects of green tea catechin extract on serum lipids in postmenopausal women: a randomized, placebo-controlled clinical trial. The American Journal of Clinical Nutrition. 2016; 104:1671-1682. DOI: 10.3945/ajcn.116.137075

[8] Zhang JY, Liao YH, Lin Y, Liu Q, Xie XM, Tang LY, Ren ZF. Effects of tea consumption and the interactions with lipids on breast cancer survival. Breast Cancer Research and Treatment.2019; 176:679-686. DOI: 10.1007/s10549- 019-05253-5

[9] Mengjie Li, Lap Ah Tse, Wingcheong Chan, Chi-hei Kwok, Siu-lan Leung, Cherry Wu, Wai-cho Yu, Ignatius Tak-sun Yu, Chloe Hui-Tung Yu, Feng Wang, Hyuna Sung, Xiaohong R. Yang. Evaluation of breast cancer risk associated with tea consumption by menopausal and estrogen receptor status among Chinese women in Hong Kong, Cancer Epidemiology. 2016; 40:73-78. DOI: 10.1016/j.canep.2015.11.013.

[10] Zhang D, Nichols HB, Troester M, Cai J, Bensen JT, Sandler DP. Tea consumption and breast cancer risk in a cohort of women with family history of breast cancer. International Journal of Cancer. 2020;147:876-886. DOI: 10.1002/ijc.32824

[11] Bezerra LS, Santos-Veloso MAO, Bezerra Junior NDS, Fonseca LCD, Sales WLA. Impacts of cytochrome P450 2D6 (CYP2D6) genetic polymorphism in tamoxifen therapy for breast cancer. Revista Brasileira de Ginecologia e Obstetrícia. 2018;40:794- 799. DOI: 10.1055/s-0038-1676303

[12] Braal CL, Hussaarts KGAM, Seuren L, Oomen-de Hoop E, de Bruijn P, Buck SAJ, Bos MEMM, Thijs-Visser MF, Zuetenhorst HJM, Mathijssen-van Stein D, Vastbinder MB, van Leeuwen RWF, van Gelder T, Koolen SLW, Jager A, Mathijssen RHJ. Influence of green tea consumption on endoxifen steady-state concentration in breast cancer patients treated with tamoxifen. Breast Cancer Research and Treatment. 2020;184:107-113. DOI: 10.1007/s10549-020-05829-6

[13] Mbuthia KS, Mireji PO, Ngure RM, Stomeo F, Kyallo M, Muoki C, Wachira FN. Tea (*Camellia sinensis*) infusions ameliorate cancer in 4TI metastatic breast cancer model. BMC Complementary and Alternative Medicine. 2017; 17:202. DOI: 10.1186/ s12906-017-1683-6

[14] Chu B, Wu S, Ji X, Chen R, Song B, Tang J, Wang H, Su Y, He Y. Controllable silicon nanostructures featuring stable fluorescence and intrinsic in vitro and in vivo anti-cancer activity. Journal of Materials Chemistry B. 2019; 7:6247- 6256. DOI: 10.1039/c9tb01191a.

[15] Farhan M, Khan HY, Oves M, Al-Harrasi A, Rehmani N, Arif H, Hadi SM, Ahmad A. Cancer therapy by catechins involves redox cycling of copper ions and generation of reactive oxygen species. Toxins.2016;8:37. DOI: 10.3390/toxins8020037.

[16] Sur S, Panda CK. Molecular aspects of cancer chemopreventive and therapeutic efficacies of tea and tea polyphenols. Nutrition. 2017;43-44:8- 15. DOI: 10.1016/j.nut.2017.06.006

[17] Romagnolo DF, Daniels KD, Grunwald JT, Ramos SA, Propper CR, Selmin OI. Epigenetics of breast cancer: Modifying role of environmental and bioactive food compounds. Molecular Nutrition & Food Research. 2016; 60:1310-1329. DOI: 10.1002/ mnfr.201501063

[18] Yiannakopoulou EC. Targeting DNA methylation with green tea catechins. Pharmacology. 2015; 95:111-116. DOI: 10.1159/000375503

[19] Chen H, Yao K, Chang X, Shim J-H, Kim HG, Malakhova M, et al. Computational and Biochemical Discovery of RSK2 as a novel target for Epigallocatechin Gallate (EGCG). PLoS ONE.2015;10: e0130049. DOI:10.1371/ journal.pone.0130049

[20] Luo X, Guo L, Zhang L, Hu Y, Shang D, Ji D. Bioinformatics analysis of microarray profiling identifies the mechanism of focal adhesion kinase signalling pathway in proliferation and apoptosis of breast cancer cells modulated by green tea polyphenol epigallocatechin 3-gallate. Journal of Pharmacy and Pharmacology. 2018; 70:1606-1618. DOI: 10.1111/jphp.13010

[21] Song X, Zhang M, Chen L, Lin Q. Bioinformatic prediction of possible targets and mechanisms of action of the green tea compound epigallocatechin-3 gallate against breast cancer. Frontiers in Molecular Biosciences. 2017; 4:43. DOI: 10.3389/fmolb.2017.00043

[22] Moradzadeh M, Hosseini A, Erfanian S, Rezaei H. Epigallocatechin-3-gallate promotes apoptosis in human breast cancer T47D cells through down-regulation of PI3K/AKT and Telomerase. Pharmacological Reports. 2017; 69:924-928. DOI: 10.1016/j.pharep. 2017.04.008.

[23] Kuban-Jankowska A, Kostrzewa T, Musial C, Barone G, Lo-Bosco G, Lo-Celso F, Gorska-Ponikowska M. Green Tea Catechins Induce Inhibition of PTP1B Phosphatase in Breast Cancer Cells with Potent Anti-Cancer Properties: In Vitro Assay, Molecular Docking, and Dynamics Studies. Antioxidants. 2020; 9:1208. DOI:10.3390/antiox9121208

[24] Liao SC, Li JX, Yu L, Sun SR. Protein tyrosine phosphatase 1B expression contributes to the development of breast cancer. Journal of Zheijang University SCIENCE B. 2017; 18:334-342. DOI: 10.1631/jzus. B1600184.

*The Use of Plants' Natural Products in Breast Cancer: Have We Already Found… DOI: http://dx.doi.org/10.5772/intechopen.96404*

[25] Romano A, Martelb F. The Role of EGCG in Breast Cancer Prevention and Therapy. Mini-Reviews in Medicinal Chemistry. 2020. DOI:10.2174/13895575 20999201211194445

[26] LazzeroniM, Guerrieri-Gonzaga A, Gandini S, Johansson H, Serrano D, Cazzaniga M, Aristarco V, Macis D, Mora S, Caldarella P, Pagani G, Pruneri G, Riva A, Petrangolini G, Morazzoni P, DeCensi A, Bonanni B. A presurgical study of lecithin formulation of green tea extract in women with early breast cancer. Cancer prevention research.2017;10:363-370. DOI: 10.1158/1940-6207.CAPR-16-0298

[27] Samavat H, Ursin G, Emory TH, Lee E, Wang R, Torkelson CJ, Dostal AM, Swenson K, Le CT, Yang CS, Yu MC, Yee D, Wu AH, Yuan JM, Kurzer MS. A randomized controlled trial of green tea extract supplementation and mammographic density in postmenopausal women at increased risk of breast cancer. Cancer Prevention Research. 2017; 10:710-718. DOI: 10.1158/1940- 6207.CAPR-17-0187

[28] Sheng J, Shi W, Guo H, Long W, Wang Y, Qi J, Liu J, Xu Y. The Inhibitory Effect of (−)-Epigallocatechin-3- Gallate on Breast Cancer Progression via Reducing SCUBE2 Methylation and DNMT Activity. Molecules. 2019; 24:2899. DOI: 10.3390/molecules 24162899

[29] Schröder L, Marahrens P, Koch JG, Heidegger H, Vilsmeier T, Phan-Brehm T, Hofmann S, Mahner S, Jeschke U, Richter DU. Effects of green tea, matcha tea and their components epigallocatechin gallate and quercetin on MCF 7 and MDA-MB-231 breast carcinoma cells. Oncology Reports. 2019;41:387-396. DOI: 10.3892/ or.2018.6789

[30] Xu P, Yan F, Zhao Y, Chen X, Sun S, Wang Y, Ying L. Green tea polyphenol EGCG attenuates MDSCs-mediated

immunosuppression through canonical and non-canonical pathways in a 4T1 murine breast cancer model. Nutrients. 2020;12:1042. DOI: 10.3390/nu12041042

[31] Liu SM, Ou SY, Huang HH. Green tea polyphenols induce cell death in breast cancer MCF-7 cells through induction of cell cycle arrest and mitochondrial-mediated apoptosis. Journal of Zheijang University SCIENCE B. 2017; 18:89-98. DOI: 10.1631/jzus. B1600022.

[32] Fujioka K, Iwamoto T, Shima H, Tomaru K, Saito H, Ohtsuka M, Yoshidome A, Kawamura Y, Manome Y. The powdering process with a set of ceramic mills for green tea promoted catechin extraction and the ROS inhibition effect. Molecules. 2016; 21:474. DOI: 10.3390/molecules21040474.

[33] Bonuccelli G, Sotgia F, Lisanti MP. Matcha green tea (MGT) inhibits the propagation of cancer stem cells (CSCs), by targeting mitochondrial metabolism, glycolysis and multiple cell signalling pathways. Aging (Albany NY). 2018; 10:1867-1883. DOI: 10.18632/ aging.101483

[34] Sinnadurai S, Okabayashi S, Kawamura T, Mori M, Bhoo-Pathy N, Aishah Taib N, Ukawa S, Tamakoshi A, The Jacc Study Group -. Intake of Common Alcoholic and Non-Alcoholic Beverages and Breast Cancer Risk among Japanese Women: Findings from the Japan Collaborative Cohort Study. Asian Pacific Journal of Cancer Prevention. 2020; 21:1701-1707. DOI: 10.31557/APJCP.2020.21.6.1701

[35] Neag MA, Mocan A, Echeverría J, Pop RM, Bocsan CI, Crişan G, Buzoianu AD. Berberine: Botanical Occurrence, Traditional Uses, Extraction Methods, and Relevance in Cardiovascular, Metabolic, Hepatic, and Renal Disorders. Frontiers in Pharmacology. 2018; 9:557. DOI: 10.3389/fphar.2018.00557

[36] Ma W, Zhang Y, Yu M, Wang B, Xu S, Zhang J, Li X, Ye X. In-vitro and in-vivo anti-breast cancer activity of synergistic effect of berberine and exercise through promoting the apoptosis and immunomodulatory effects. International Immunopharmacology. 2020; 87:106787. DOI: 10.1016/j.intimp.2020.106787

[37] Han B, Wang K, Tu Y, Tan L, He C. Low-dose berberine attenuates the anti-breast cancer activity of chemotherapeutic agents via induction of autophagy and antioxidation. Dose Response. 2020; 18:1559325820939751. DOI: 10.1177/1559325820939751

[38] El Khalki L, Tilaoui M, Jaafari A, Ait Mouse H, Zyad A. Studies on the Dual Cytotoxicity and Antioxidant Properties of *Berberis vulgaris* Extracts and Its Main Constituent Berberine. Advances in Pharmacological Scienses. 2018; 2018:3018498. DOI: 10.1155/2018/3018498.

[39] Belwal T, Bisht A, Devkota HP, Ullah H, Khan H, Pandey A, Bhatt ID, Echeverría J. Phytopharmacology and Clinical Updates of Berberis Species Against Diabetes and Other Metabolic Diseases.Frontiers in Pharmacology. 2020;11:41. DOI: 10.3389/fphar. 2020.00041

[40] Karnam KC, Ellutla M, Bodduluru LN, Kasala ER, Uppulapu SK, Kalyankumarraju M, Lahkar M. Preventive effect of berberine against DMBA-induced breast cancer in female Sprague Dawley rats. Biomedicine & Pharmacotherapy. 2017; 92:207-214. DOI: 10.1016/j.biopha.2017.05.069

[41] Kim S, Lee J, You D, Jeong Y, Jeon M, Yu J, Kim SW, Nam SJ, Lee JE. Berberine Suppresses Cell Motility Through Downregulation of TGF-β1 in Triple Negative Breast Cancer Cells. Cellular Physiology and Biochemistry. 2018; 45: 795-807. DOI: 10.1159/000487171

[42] Su K, Hu P, Wang X, Kuang C, Xiang Q, Yang F, Xiang J, Zhu S, Wei L, Zhang J. Tumor suppressor berberine binds VASP to inhibit cell migration in basal-like breast cancer. Oncotarget. 2016; 7:45849-45862. DOI: 10.18632/ oncotarget.9968

[43] Zhao Y, Jing Z, Lv J, Zhang Z, Lin J, Cao X, Zhao Z, Liu P, Mao W. Berberine activates caspase-9/cytochrome c-mediated apoptosis to suppress triple-negative breast cancer cells in vitro and in vivo. Biomedicine and Pharmacotherapy. 2017; 95:18-24. DOI: 10.1016/j.biopha.2017.08.045

[44] Ma W, Zhu M, Zhang D, Yang L, Yang T, Li X, Zhang Y. Berberine inhibits the proliferation and migration of breast cancer ZR-75-30 cells by targeting Ephrin-B2. Phytomedicine. 2017; 25:45- 51. DOI: 10.1016/j.phymed.2016.12.013

[45] Pan Y, Zhang F, Zhao Y, Shao D, Zheng X, Chen Y, He K, Li J, Chen L. Berberine enhances chemosensitivity and induces apoptosis through doseorchestrated AMPK signaling in breast cancer. Journal of Cancer. 2017; 8:1679- 1689. DOI: 10.7150/jca.19106

[46] Jeong Y, You D, Kang HG, Yu J, Kim SW, Nam SJ, Lee JE, Kim S. Berberine suppresses fibronectin expression through inhibition of c-Jun phosphorylation in breast cancer cells. Journal of Breast Cancer. 2018; 21:21-27. DOI: 10.4048/jbc.2018.21.1.21

[47] Ahmadiankia N, Moghaddam HK, Mishan MA, Bahrami AR, Naderi-Meshkin H, Bidkhori HR, Moghaddam M, Mirfeyzi SJ. Berberine suppresses migration of MCF-7 breast cancer cells through down-regulation of chemokine receptors. Iranian Journal of Basic Medical Sciences. 2016; 19:125- 131. DOI:10.22038/IJBMS.2016.6531

[48] Sakaguchi M, Kitaguchi D, Morinami S, Kurashiki Y, Hashida H, Miyata S, Yamaguchi M, Sakai M,

*The Use of Plants' Natural Products in Breast Cancer: Have We Already Found… DOI: http://dx.doi.org/10.5772/intechopen.96404*

Murata N, Tanaka S. Berberine-induced nucleolar stress response in a human breast cancer cell line. Biochemical and Biophysical Research Communications.2020 ;528:227-233. DOI: 10.1016/j.bbrc.2020.05.020

[49] Sun Y, Wang W, Tong Y. Berberine inhibits proliferative ability of breast cancer cells by reducing metadherin. Medical Science Monitor. 2019; 25:9058- 9066. DOI: 10.12659/MSM.914486.

[50] Zhao L, Zhang C. Berberine Inhibits MDA-MB-231 Cells by attenuating their inflammatory responses. BioMed Research International. 2020; 16:3617514. DOI: 10.1155/2020/3617514

[51] Yao M, Fan X, Yuan B, Takagi N, Liu S, Han X, Ren J, Liu J. Berberine inhibits NLRP3 Inflammasome pathway in human triple-negative breast cancer MDA-MB-231 cell. BMC Complementary and Alternative Medicine. 2019;19:216. DOI: 10.1186/ s12906-019-2615-4

[52] Kim S, You D, Jeong Y, Yu J, Kim SW, Nam SJ, Lee JE. Berberine down-regulates IL-8 expression through inhibition of the EGFR/MEK/ERK pathway in triple-negative breast cancer cells. Phytomedicine. 2018; 50:43-49. DOI: 10.1016/j.phymed.2018.08.004

[53] Sefidabi R, Mortazavi P, Hosseini S. Antiproliferative effect of berberine on canine mammary gland cancer cell culture. Biomedical Reports. 2017; 6:95- 98. DOI: 10.3892/br.2016.809

[54] PonnusamyL, Kothandan G, Manoharan R. Berberine and Emodin abrogates breast cancer growth and facilitates apoptosis through inactivation of SIK3-induced mTOR and Akt signaling pathway. Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease. 2020; 1866:165897. DOI: 10.1016/j.bbadis.2020.165897

[55] Zhang R, Qiao H, Chen S, Chen X, Dou K, Wei L, Zhang J. Berberine reverses lapatinib resistance of HER2-positive breast cancer cells by increasing the level of ROS. Cancer Biology & Therapy. 2016; 17:925-934. DOI: 10.1080/15384047.2016.1210728

[56] Wang Y, Liu Y, Du X, Ma H, Yao J. Berberine reverses doxorubicin resistance by inhibiting autophagy through the PTEN/Akt/mTOR signaling pathway in breast cancer. OncoTargets and Therapy. 2020; 13:1909-1919. DOI: 10.2147/OTT.S241632

[57] Hashemi-Niasari F, Rabbani-Chadegani A, Razmi M, Fallah S. Synergy of theophylline reduces necrotic effect of berberine, induces cell cycle arrest and PARP, HMGB1, Bcl-2 family mediated apoptosis in MDA-MB-231 breast cancer cells. Biomedicine & Pharmacotherapy. 2018; 106:858-867. DOI: 10.1016/j. biopha.2018.07.019.

[58] Gao X, Wang J, Li M, Wang J, Lv J, Zhang L, Sun C, Ji J, Yang W, Zhao Z, Mao W. Berberine attenuates XRCC1 mediated base excision repair and sensitizes breast cancer cells to the chemotherapeutic drugs. Journal of Cellular and Molecular Medicine. 2019; 23:6797-6804. DOI: 10.1111/jcmm.14560

[59] Wen C, Wu L, Fu L, Zhang X, Zhou H. Berberine enhances the antitumor activity of tamoxifen in drugsensitive MCF-7 and drug-resistant MCF-7/TAM cells. Molecular Medicine Reports.2016; 14:2250-2256. DOI: 10.3892/mmr.2016.5490

[60] Du J, Sun Y, Lu YY, Lau E, Zhao M, Zhou QM, Su SB. Berberine and Evodiamine act synergistically against human breast cancer MCF-7 Cells by inducing cell cycle arrest and apoptosis. Anticancer Research. 2017; 37:6141-6151. DOI: 10.21873/anticanres.12063

[61] Khan I, Joshi G, Nakhate KT, Ajazuddin, Kumar R, Gupta U. Nano-Co-Delivery of Berberine and

Anticancer Drug Using PLGA Nanoparticles: exploration of better anticancer activity and in vivo kinetics. Pharmaceutical Research. 2019; 36:149. DOI: 10.1007/s11095-019-2677-5.

[62] Bhanumathi R, Manivannan M, Thangaraj R, Kannan S. Drug-carrying capacity and anticancer effect of the folic acid- and berberine-loaded silver nanomaterial to regulate the AKT-ERK pathway in breast cancer. ACS Omega. 2018; 3:8317-8328. DOI: 10.1021/ acsomega.7b01347

[63] Linjawi S A A, Khalil W K B, M. Hassanane M, Ahmed E S. Evaluation of the protective effect of *Nigella sativa* extract and its primary active component thymoquinone against DMBA-induced breast cancer in female rats. Archives of Medical Science. 2015; 11:220-229. DOI:10.5114/ aoms.2013.33329.

[64] Imran M, Rauf A, Khan IA, Shahbaz M, Qaisrani TB, Fatmawati S, Abu-Izneid T, Imran A, Rahman KU, Gondal TA. Thymoquinone: A novel strategy to combat cancer: A review. Biomedicine & Pharmacotherapy. 2018; 106:390-402. DOI: 10.1016/j. biopha.2018.06.159

[65] Şakalar Ç, İzgi K, İskender B, Sezen S, Aksu H, Çakır M, Kurt B, Turan A, Canatan H. The combination of thymoquinone and paclitaxel shows anti-tumor activity through the interplay with apoptosis network in triple-negative breast cancer. Tumour Biology. 2016; 37:4467-77. DOI: 10.1007/ s13277-015-4307-0

[66] Ünal TD, Hamurcu Z, Delibaşı N, Çınar V, Güler A, Gökçe S, Nurdinov N, Ozpolat B. Thymoquinone inhibits proliferation and migration of mda-mb-231 triple negative breast cancer cells by suppressing autophagy and beclin-1 and lc3. Anti-Cancer Agents in Medicinal Chemistry. 2020;

21: 355-364. DOI:10.2174/187152062066 6200807221047

[67] Sundaravadivelu S, Raj SK, Kumar BS, Arumugamand P, Ragunathan PP. Reverse screening bioinformatics approach to identify potential anti breast cancer targets using thymoquinone from neutraceuticals Black Cumin Oil. Anti-Cancer Agents in Medicinal Chemistry.2019;19:599-609. DOI: 10.2174/187152061966619 0124155359

[68] Aslan M, Afşar E, Kırımlıoglu E, Çeker T, Yılmaz Ç. Antiproliferative Effects of Thymoquinone in MCF-7 Breast and HepG2 Liver Cancer Cells: Possible Role of Ceramide and ER Stress. Nutrition and Cancer. 2020; 14:1- 13. DOI: 10.1080/01635581.2020.1751216

[69] Khan A, Aldebasi YH, Alsuhaibani SA, Khan MA. Thymoquinone augments cyclophosphamide-mediated inhibition of cell proliferation in breast cancer cells. Asian Pacific Journal of Cancer Prevention. 2019; 20:1153-1160. DOI: 10.31557/APJCP.2019.20.4.1153.

[70] Alobaedi, O.H. W.H. Talib, I.A. Basheti.Antitumor effect of thymoquinone combined with resveratrol on mice transplanted with breast cancer. Asian Pacific Journal of Tropical Medicine.2017; 10:400-408. DOI: 10.1016/j.apjtm.2017.03.026

[71] Talib WH. Regressions of breast carcinoma syngraft following treatment with piperine in combination with thymoquinone. Scientia Pharmaceutica. 2017; 85:27. DOI: 10.3390/ scipharm85030027.

[72] Odeh LH, Talib WH, Basheti IA. Synergistic effect of thymoquinone and melatonin against breast cancer implanted in mice. Journal of Cancer Research and Therapeutics. 2018 ;14: S324-S330. DOI: 10.4103/0973-1482. 235349

*The Use of Plants' Natural Products in Breast Cancer: Have We Already Found… DOI: http://dx.doi.org/10.5772/intechopen.96404*

[73] Bashmail HA, Alamoudi AA, Noorwali A, Hegazy GA, AJabnoor G, Choudhry H, Al-Abd AM. Thymoquinone synergizes gemcitabine antibreast cancer activity via modulating its apoptotic and autophagic activities. Scientific Reports. 2018; 8:11674. DOI: 10.1038/s41598-018-30046-z

[74] Ibiyeye KM, Nordin N, Ajat M, Zuki ABZ. Ultrastructural changes and antitumor effects of doxorubicin/ thymoquinone-loaded CaCO3 nanoparticles on breast cancer cell line. Frontiers in Oncology. 2019; 9:599. DOI: 10.3389/fonc.2019.00599.

[75] Khan M, Tania M, Wei C, Mei Z, Fu S, Cheng J, Xu J, Fu J. Thymoquinone inhibits cancer metastasis by downregulating TWIST1 expression to reduce epithelial to mesenchymal transition. Oncotarget. 2015; 6: 19580-19591.

[76] Bhattacharjee M, Upadhyay P, Sarker S, Basu A, Das S, Ghosh A, Ghosh S, Adhikary A. Combinatorial therapy of Thymoquinone and Emodin synergistically enhances apoptosis, attenuates cell migration and reduces stemness efficiently in breast cancer. Biochimica et Biophysica Acta General Subjects. 2020; 1864:129695. DOI: 10.1016/j.bbagen.2020.129695

[77] Shanmugam MK, Ahn KS, Hsu A, Woo CC, Yuan Y, Tan KHB, Chinnathambi A, Alahmadi TA, Alharbi SA, Koh APF, Arfuso F, Huang RY, Lim LHK, Sethi G, Kumar AP. Thymoquinone inhibits bone metastasis of breast cancer cells through abrogation of the cxcr4 signaling axis. Frontiers in Pharmacology. 2018; 9:1294. DOI: 10.3389/fphar.2018.01294

[78] Bhattacharya S, Ahir M, Patra P, Mukherjee S, Ghosh S, Mazumdar M, Chattopadhyay S, Das T, Chattopadhyay D, Adhikary A. PEGylated-thymoquinone-nanoparticle mediated retardation of breast cancer

cell migration by deregulation of cytoskeletal actin polymerization through miR-34a. Biomaterials. 2015;51:91-107. DOI: 10.1016/j. biomaterials.2015.01.007

[79] Ong YS, Saiful Yazan L, Ng WK, Abdullah R, Mustapha NM, Sapuan S, Foo JB, Tor YS, How CW, Abd Rahman N, Zakarial Ansar FH. Thymoquinone loaded in nanostructured lipid carrier showed enhanced anticancer activity in 4T1 tumor-bearing mice. Nanomedicine. 2018; 13:1567-1582. DOI: 10.2217/ nnm-2017-0322.

[80] Zafar S, Akhter S, Ahmad I, Hafeez Z, Alam Rizvi MM, Jain GK, Ahmad FJ. Improved chemotherapeutic efficacy against resistant human breast cancer cells with co-delivery of docetaxel and thymoquinone by chitosan grafted lipid nanocapsules: formulation optimization, in vitro and in vivo studies. Colloids and Surfaces B Biointerfaces. 2020;186:110603. DOI: 10.1016/j.colsurfb.2019.110603

[81] Mehanna MM, Sarieddine R, Alwattar JK, Chouaib R, Gali-Muhtasib H. Anticancer Activity of Thymoquinone Cubic Phase Nanoparticles Against Human Breast Cancer: Formulation, Cytotoxicity and Subcellular Localization. International Journal of Nanomedicine. 2020;15:9557-9570. DOI: 10.2147/ IJN.S263797

[82] Kommineni N, Saka R, Bulbake U, Khan W. Cabazitaxel and thymoquinone co-loaded lipospheres as a synergistic combination for breast cancer. Chemistry and Physics of Lipids. 2019; 224:104707. DOI: 10.1016/j. chemphyslip.2018.11.009.

[83] Elbaz M, Nasser MW, Ravi J, Wani NA, Ahirwar DK, Zhao H, Oghumu S, Satoskar AR, Shilo K, Carson WE 3rd, Ganju RK. Modulation of the tumor microenvironment and inhibition of EGF/EGFR pathway: novel

anti-tumor mechanisms of Cannabidiol in breast cancer. Molecular Oncology. 2015; 9:906-919. DOI: 10.1016/j. molonc.2014.12.010

[84] Mokoena D, George B, Abrahamse H. Enhancing Breast Cancer Treatment Using a Combination of Cannabidiol and Gold Nanoparticles for Photodynamic Therapy. International Journal of Molecular Sciences.2019; 20:4771. DOI: 10.3390/ijms20194771

[85] Śledziński P, Zeyland J, Słomski R, Nowak A. The current state and future perspectives of cannabinoids in cancer biology. Cancer Medicine. 2018;7: 765- 775.DOI: 10.1002/cam4.1312.

[86] Pérez-Gómez E, Andradas C, Blasco-Benito S, Caffarel MM, García-Taboada E, Villa-Morales M, Moreno E, Hamann S, Martín-Villar E, Flores JM, Wenners A, Alkatout I, Klapper W, Röcken C, Bronsert P, Stickeler E, Staebler A, Bauer M, Arnold N, Soriano J, Pérez-Martínez M, Megías D, Moreno-Bueno G, Ortega-Gutiérrez S, Artola M, Vázquez-Villa H, Quintanilla M, Fernández-Piqueras J, Canela EI, McCormick PJ, Guzmán M, Sánchez C. Role of cannabinoid receptor CB2 in HER2 pro-oncogenic signaling in breast cancer. Journal of the National Cancer Institute. 2015;107: djv077. DOI: 10.1093/jnci/djv077

[87] Kosgodage US, Mould R, Henley AB, Nunn AV, Guy GW, Thomas EL, Inal JM, Bell JD, Lange S. Cannabidiol (CBD) is a novel inhibitor for exosome and microvesicle (EMV) release in cancer. Frontiers in Pharmacology. 2018; 9:889. DOI: 10.3389/fphar.2018.00889

[88] Sultan AS, Marie MA, Sheweita SA. Novel mechanism of cannabidiolinduced apoptosis in breast cancer cell lines. Breast. 2018; 41:34-41. DOI: 10.1016/j.breast.2018.06.009

[89] García-Morales L, Castillo AM, Tapia Ramírez J, Zamudio-Meza H, Domínguez-Robles MDC, Meza I. CBD Reverts the mesenchymal invasive phenotype of breast cancer cells induced by the inflammatory cytokine IL-1β. International Journal of Molecular Sciences. 2020;21:2429. DOI: 10.3390/ ijms21072429

[90] Elbaz M, Ahirwar D, Xiaoli Z, Zhou X, Lustberg M, Nasser MW, Shilo K, Ganju RK. TRPV2 is a novel biomarker and therapeutic target in triple negative breast cancer. Oncotarget. 2016; 9:33459-33470. DOI: 10.18632/oncotarget.9663.

[91] Fraguas-Sánchez AI, Fernández-Carballido A, Simancas-Herbada R, Martin-Sabroso C, Torres-Suárez AI. CBD loaded microparticles as a potential formulation to improve paclitaxel and doxorubicinbased chemotherapy in breast cancer. International Journal of Pharmaceutics.2020;574:118916. DOI: 10.1016/j.ijpharm.2019.118916

[92] Schoeman R, Beukes N, Frost C. Cannabinoid combination induces cytoplasmic vacuolation in mcf-7 breast cancer cells. Molecules. 2020; 25:4682. DOI: 10.3390/molecules25204682.

[93] Parihar V, Rogers A, Blain AM, Zacharias SRK, Patterson LL, Siyam MA. Reduction in tamoxifen metabolites Endoxifen and N-desmethyltamoxifen with chronic administration of low dose cannabidiol: A CYP3A4 and CYP2D6 Drug Interaction. Journal of Pharmacy Practice. 2020; 15:897190020972208. DOI: 10.1177/0897190020972208

[94] Tomko A, O'Leary L, Trask H, Achenbach JC, Hall SR, Goralski KB, Ellis LD, Dupré DJ. Antitumor activity of abnormal cannabidiol and its analog o-1602 in taxol-resistant preclinical models of breast cancer. Frontiers in Pharmacology. 2019; 10:1124. DOI: 10.3389/fphar.2019.01124.

*The Use of Plants' Natural Products in Breast Cancer: Have We Already Found… DOI: http://dx.doi.org/10.5772/intechopen.96404*

[95] Blasco-Benito S, Seijo-Vila M, Caro-Villalobos M, Tundidor I, Andradas C, García-Taboada E, Wade J, Smith S, Guzmán M, Pérez-Gómez E, Gordon M, Sánchez C. Appraising the "entourage effect": Antitumor action of a pure cannabinoid versus a botanical drug preparation in preclinical models of breast cancer. Biochemical Pharmacology. 2018; 157:285-293. DOI: 10.1016/j.bcp.2018.06.025

[96] Kenyon J, Liu W, Dalgleish A. Report of objective clinical responses of cancer patients to pharmaceuticalgrade synthetic cannabidiol. Anticancer Research. 2018; 38:5831-5835. DOI: 10.21873/anticanres.12924.

[97] Pellati F, Borgonetti V, Brighenti V, Biagi M, Benvenuti S, Corsi L. *Cannabis sativa* L. and Nonpsychoactive Cannabinoids: Their Chemistry and Role against Oxidative Stress, Inflammation, and Cancer. BioMed Research International. 2018; 4:1691428. DOI: 10.1155/2018/1691428

[98] Kisková T, Mungenast F, Suváková M, Jäger W, Thalhammer T. Future aspects for cannabinoids in breast cancer therapy. International Journal of Molecular Sciences. 2019; 20:1673. DOI: 10.3390/ijms20071673

## **Chapter 6**
