Total dietary antioxidant index and survival in patients with glioblastoma multiforme

Chinese Dietary Indices and Glioma: New Insights of a Case-Control Study in the Chinese Population

Identifying modifiable factors in primary prevention strategies is a typical goal of glioma epidemiology. Among many glioma risk factors, diet was always considered as one. Most of the relevant studies thus far were concentrated on the West. It was crucial to investigate the connection between the Chinese diet and gliomas given the stark variations between western and eastern diets. A food frequency questionnaire including 114 items was used to investigate the food intake of the study subjects. The Chinese Dietary Quality Index (CDQI), the Chinese Dietary Balance Index (CDBI), the Dietary Antioxidant Index (DAI), the Dietary Inflammation Index (DII), and the Chinese Healthy Eating Index (CHEI) were calculated based on the data provided by the food frequency questionnaire to evaluate dietary quality, dietary balance, dietary antioxidants, dietary inflammation and adherence to the Chinese dietary guidelines in 506 glioma patients and 506 controls, respectively. After adjusting covariates, CHEI (OR = 0.90, 95% CI: 0.88-0.93) and DAI (OR = 0.61, 95% CI: 0.54-0.70) were correlated to a reduced glioma risk, and CDBI-based undernutrition (OR = 1.08, 95% CI: 1.06-1.12) and overnutrition (OR = 1.14, 95% CI: 1.09-1.20) and DII (OR = 2.20, 95% CI: 1.81-2.68) were correlated to an elevated glioma risk. Moreover, restrictive cubic spline analysis showed that there were significant nonlinear dose-response relationships between CHEI, CDBI, DAI, DII, and glioma. Therefore, adhering to the Chinese dietary guidelines was connected with a lower glioma risk, and undernutrition and overnutrition in the Chinese diet were associated with an increased risk of glioma.

Use of Complementary and Integrative Medicine Among Patients With Glioblastoma Multiforme Seen at a Tertiary Care Center

Background

Glioblastoma multiforme (GBM) is among the most aggressive and lethal tumors, with a median survival of 12-15 months. Many patients use complementary and integrative medicine (CIM) therapies to supplement their cancer treatment.

Objective

To determine the prevalence of CIM use and identify the most frequently used types of CIM in a cohort of patients with GBM seen at a tertiary care medical center in the United States.

Methods

An anonymous survey was mailed through the US Postal Service from August 1, 2019, through February 21, 2020, to patients with GBM.

Results

A total of 346 surveys were mailed, and 146 responses (42%) were received. The median age of respondents was 61 years (range, 52-68 years), and 85 (58%) were male. Most patients had undergone surgery (90%), chemotherapy (96%), and radiotherapy (95%). The median time from diagnosis of GBM to survey participation was 18 months (range, 12-31 months). Most respondents (81%) used some form of CIM, most frequently meditation (22%), relaxation and other stress management techniques (19%), chiropractic therapy (16%), and acupuncture (12%). Compared with men, women more commonly meditated (32% vs 16%; P = .046) and practiced yoga (20% vs 6%; P = .04). We observed age-based differences, with younger patients more commonly meditating, practicing relaxation and stress management techniques, and receiving chiropractic therapy (P < .05 for all).

Conclusions

Providers should encourage patients with GBM to discuss their interest in CIM therapies and guide them to evidence-based treatments that may help improve their quality of life.

Safety and Efficacy Assessments to Take Antioxidants in Glioblastoma Therapy: From In Vitro Experiences to Animal and Clinical Studies

Glioblastoma (GBM) is considered one of the most common malignant brain tumors, occurring as over 15% of all primary central nervous system and brain neoplasms. The unique and standard treatment option towards GBM involves the combination of surgical resection followed by radiotherapy (RT) and chemotherapy (CT). However, due to the aggressive nature and heterogeneity of GBMs, they remained difficult to treat. Recent findings from preclinical studies have revealed that disruption of the redox balance via using either oxidative or anti-oxidative agents in GBM presented an effective and promising therapeutic approach. A limited number of clinical trials substantially encouraged their concomitant use with RT or CT. Thus, treatment of GBMs may benefit from natural or synthetic antioxidative compounds as novel therapeutics. Despite the presence of variegated in vitro and in vivo studies focusing on safety and efficacy issues of these promising therapeutics, nowadays their translation to clinics is far from applicability due to several challenges. In this review, we briefly introduce the enzymatic and non-enzymatic antioxidant defense systems as well as potential signaling pathways related to the pathogenesis of GBM with a special interest in antioxidant mechanisms. In addition, we describe the advantages and limitations of antioxidant supplementation in GBM cases or disease models as well as growing challenges for GBM therapies with antioxidants in the future.

Complementary and Alternative Medicine for the Treatment of Gliomas: Scoping Review of Clinical Studies, Patient Outcomes, and Toxicity Profiles

INTRODUCTION

Complementary and alternative medicine (CAM) are highly used among those diagnosed with glioma. Further research is warranted, however, as it remains important to clearly delineate CAM practices that are unproven, disproven, or promising for future research and implementation.

METHODS

A systematic review was conducted to identify all articles that investigated the effect of any CAM therapy on survival of patients with newly diagnosed or recurrent glioma.

RESULTS

Eighteen papers and 4 abstracts pertaining to the effects of ketogenic diet (4), antioxidants (3), hyperbaric oxygen (4), cannabinoids (2), carbogen and nicotinamide (3), mistletoe extract (2), hypocupremia and penicillamine (1), and overall CAM use (3) on overall and progression-free survival in patients with low- and high-grade glioma were identified (Levels of Evidence I-IV). Ketogenic diets, hyperbaric oxygen therapy, and cannabinoids appear to be safe and well tolerated by patients; preliminary studies demonstrate tumor response and increased progression-free survival and overall survival when combined with standard of care therapies. Antioxidant usage exhibit mixed results perhaps associated with glioma grade with greater effect on low-grade gliomas; vitamin D intake was associated with prolonged survival. Conversely, carbogen breathing and hypocupremia were found to have no effect on the survival of patients with glioma, with associated significant toxicity. Most modalities under the CAM umbrella have not been appropriately studied and require further investigation.

CONCLUSIONS

Despite widespread use, Level I or II evidence for CAM for the treatment of glioma is lacking, representing future research directions to optimally counsel and treat glioma patients.

The Association between Dietary Total Antioxidant Capacity and Glioma in Adults

OBJECTIVE

We assessed the relation between dietary total antioxidant capacity (TAC) and risk of glioma among Iranian adults. Design: A hospital-based case-control study. Setting: This case-control investigation was done in 2011. Usual dietary intakes of participants during the preceding year were examined using a food frequency questionnaire. Data on dietary TAC from foods was gathered from published databases that provided the antioxidant capacity for each food item, measured by ferric reducing antioxidant power. Participants: Cases were individuals with pathologically confirmed glioma that were diagnosed during the last month (n = 128). Controls were individuals, aged between 20 and 75 years, who were hospitalized or were outpatients referred to other wards of the same hospitals (n = 256). Results: Compared with participants in the lowest quartile, those in the highest quartile of dietary TAC had a lower odds of glioma (OR: 0.28, 95%CI: 0.15-0.45). This association was strengthened when potential confounders were taken into account (OR: 0.13; 95%CI: 0.05-0.35). Such inverse association was also seen for men (OR: 0.05, 95%CI: 0.01-0.19), but not for women. Furthermore, significant inverse associations were seen between dietary intakes of vitamin C (OR for Q₄ vs. Q₁: 0.14, 95%CI: 0.05-0.36; P-trend < 0.01), vitamin B6 (OR for Q₄ vs. Q₁: 0.35, 95%CI: 0.13-0.97; P-trend = 0.02) and β-carotene (OR for Q₃ vs. Q₁: 0.43, 95%CI: 0.19-0.98; P-trend = 0.57) and glioma, after controlling for potential covariates. Conclusions: We found that dietary TAC as well as dietary intake of vitamin C, vitamin B6, and β-carotene was inversely associated with odds of glioma in adults.

The Influence of Nutritional and Lifestyle Factors on Glioma Incidence

Cancers are the first main cause of premature death in developed countries. Since brain tumors, especially gliomas, are the most lethal type of cancers, risk factors for their prevalence are still being discussed. Nearly 30–50% of all cancers could be prevented by proper nutritional habits and other lifestyle factors, but their influence on the tumors of the central nervous system has not been explained completely and still requires further studies. That is why we attempted to review the available research in this field, with a special focus on the factors with the proven protective activity observed in other cancers. Adequate vegetables and antioxidants (such as vitamins C and A) provided with a diet could have a protective effect, while other factors have shown no correlation with the incidence of glioma. However, further studies are necessary to determine whether fish, coffee, and tea consumption may prevent glioma. Maintaining proper body weight and undertaking a sufficient level of daily physical activity also seem to be important. Excessive body mass index (BMI) and higher attained height have increased the risk of glioma. In order to link more accurately the chosen factors to the prevalence of gliomas, it seems necessary to conduct large cohort, prospective, controlled studies in different world regions.

Total Antioxidant Capacity and Pancreatic Cancer Incidence and Mortality in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

BACKGROUND

Total antioxidant capacity (TAC) reflects an individual's overall antioxidant intake. We sought to clarify whether higher TAC is associated with lower risks of pancreatic cancer incidence and mortality in the U.S. general population.

METHODS

A total of 96,018 American adults were identified from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. A ferric-reducing ability of plasma score was used to reflect an individual's TAC intake from diet and/or supplements. Cox regression was used to calculate hazard ratios (HR) for pancreatic cancer incidence, and competing risk regression was used to calculate subdistribution HRs for pancreatic cancer mortality. Restricted cubic spline regression was used to test nonlinearity.

RESULTS

A total of 393 pancreatic cancer cases and 353 pancreatic cancer-related deaths were documented. Total (diet + supplements) TAC was found to be inversely associated with pancreatic cancer incidence (HR _{quartile 4 vs. quartile 1} = 0.53; 95% confidence interval, 0.39-0.72; P _trend = 0.0002) and mortality (subdistribution HR _{quartile 4 vs. quartile 1} = 0.52; 95% confidence interval 0.38-0.72; P _trend = 0.0003) in a nonlinear dose-response manner (all P _nonlinearity < 0.01). Similar results were observed for dietary TAC. No association of supplemental TAC with pancreatic cancer incidence and mortality was found.

CONCLUSIONS

In the U.S. general population, dietary but not supplemental TAC level is inversely associated with risks of pancreatic cancer incidence and mortality in a nonlinear dose-response pattern.

IMPACT

This is the first prospective study indicating that a diet rich in antioxidants may be beneficial in decreasing pancreatic cancer incidence and mortality.

Case-specific potentiation of glioblastoma drugs by pterostilbene

Glioblastoma multiforme (GBM, astrocytoma grade IV) is the most common malignant primary brain tumor in adults. Addressing the shortage of effective treatment options for this cancer, we explored repurposing of existing drugs into combinations with potent activity against GBM cells. We report that the phytoalexin pterostilbene is a potentiator of two drugs with previously reported anti-GBM activity, the EGFR inhibitor gefitinib and the antidepressant sertraline. Combinations of either of these two compounds with pterostilbene suppress cell growth, viability, sphere formation and inhibit migration in tumor GBM cell (GC) cultures. The potentiating effect of pterostilbene was observed to a varying degree across a panel of 41 patient-derived GCs, and correlated in a case specific manner with the presence of missense mutation of EGFR and PIK3CA and a focal deletion of the chromosomal region 1p32. We identify pterostilbene-induced cell cycle arrest, synergistic inhibition of MAPK activity and induction of Thioredoxin interacting protein (TXNIP) as possible mechanisms behind pterostilbene's effect. Our results highlight a nontoxic stilbenoid compound as a modulator of anticancer drug response, and indicate that pterostilbene might be used to modulate two anticancer compounds in well-defined sets of GBM patients.

Antioxidants delay clinical signs and systemic effects of ENU induced brain tumors in rats

According to our previous study suggesting that antioxidant properties of phytochemicals in the diet decrease glioma aggressiveness, we used a SUVIMAX-like diet ("Supplementation en VItamines et Minéraux AntioXydants") (enriched with alpha-tocopherol, beta carotene, vitamin C, zinc, and sodium selenite), adapted to rats. The present results showed that each of the antioxidants inhibited growth of glioma cells in vitro. When used in combination for in vivo studies, we showed a highly significant delay in the clinical signs of the disease, but not a statistical significant difference in the incidence of glioma in an Ethyl-nitrosourea (ENU)-model. The SUVIMAX-like diet decreased candidate markers of tumoral aggressiveness and gliomagenesis progression. The mRNA expressions of 2 common markers in human glioma: Mn-SOD (Manganese Superoxide Dismutase) and IGFBP5 (insulin growth factor binding protein) were reduced in the tumors of rats fed the antioxidant diet. In addition, the transcripts of two markers linked to brain tumor proliferation, PDGFRb (platelet-derived growth factor receptor beta) and Ki-67, were also significantly decreased. On the whole, our results suggest a protective role for antioxidants to limit aggressiveness and to some extent, progression of gliomas, in a rat model.

Association between body mass index and mortality in patients with glioblastoma mutliforme

PURPOSE

To examine the association between obesity and survival in patients with glioblastoma mutliforme (GBM) METHODS: Using a prospective design, 1,259 patients with previously untreated GBM were recruited between 1991 and 2008. Height and weight were self-reported or abstracted from medical records at study entry and used to calculate body mass index (BMI) [weight (kg)/[height (m)](2). Cox proportional models were used to estimate the risk of death associated with BMI as a continuous variable or categorized using established criteria (normal weight, 18.5-24.9 kg/m(2); overweight, 25.0-29.9 kg/m(2); obese, ≥ 30.0 kg/m(2)).

RESULTS

Median follow-up was 40 months, and 1,069 (85%) deaths were observed during this period. For all patients, minimal adjusted analyses indicated no significant association between BMI treated as a continuous variable and survival. Compared with patients with a BMI 18.5-24.9 kg/m(2), the minimally adjusted HR for overall survival was 1.08 (95% CI, 0.94-1.24) for a BMI 25-29.9 kg/m(2) and 1.08 (95% CI, 0.91-28) for a BMI ≥ 30.0 kg/m(2). After additional adjustment for adjuvant therapy, the HR for those with a BMI of 25.0-29.9 kg/m(2) was 1.14 (95% CI, 0.99-1.32) and 1.09 (95% CI, 0.91-1.30) for those with a BMI ≥ 30.0 kg/m(2). No significant interactions were revealed for BMI and any demographic variables.

CONCLUSION

BMI was not associated with survival in newly diagnosed and previously untreated patients with GBM. Further research investigating the prognostic significance of alternative, quantitative measures of body habitus, and functional performance are required.

Daily intake of antioxidants in relation to survival among adult patients diagnosed with malignant glioma

BACKGROUND

Malignant glioma is a rare cancer with poor survival. The influence of diet and antioxidant intake on glioma survival is not well understood. The current study examines the association between antioxidant intake and survival after glioma diagnosis.

METHODS

Adult patients diagnosed with malignant glioma during 1991-1994 and 1997-2001 were enrolled in a population-based study. Diagnosis was confirmed by review of pathology specimens. A modified food-frequency questionnaire interview was completed by each glioma patient or a designated proxy. Intake of each food item was converted to grams consumed/day. From this nutrient database, 16 antioxidants, calcium, a total antioxidant index and 3 macronutrients were available for survival analysis. Cox regression estimated mortality hazard ratios associated with each nutrient and the antioxidant index adjusting for potential confounders. Nutrient values were categorized into tertiles. Models were stratified by histology (Grades II, III, and IV) and conducted for all (including proxy) subjects and for a subset of self-reported subjects.

RESULTS

Geometric mean values for 11 fat-soluble and 6 water-soluble individual antioxidants, antioxidant index and 3 macronutrients were virtually the same when comparing all cases (n=748) to self-reported cases only (n=450). For patients diagnosed with Grade II and Grade III histology, moderate (915.8-2118.3 mcg) intake of fat-soluble lycopene was associated with poorer survival when compared to low intake (0.0-914.8 mcg), for self-reported cases only. High intake of vitamin E and moderate/high intake of secoisolariciresinol among Grade III patients indicated greater survival for all cases. In Grade IV patients, moderate/high intake of cryptoxanthin and high intake of secoisolariciresinol were associated with poorer survival among all cases. Among Grade II patients, moderate intake of water-soluble folate was associated with greater survival for all cases; high intake of vitamin C and genistein and the highest level of the antioxidant index were associated with poorer survival for all cases.

CONCLUSIONS

The associations observed in our study suggest that the influence of some antioxidants on survival following a diagnosis of malignant glioma are inconsistent and vary by histology group. Further research in a large sample of glioma patients is needed to confirm/refute our results.