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Schmidt K, Thatcher A, Grobe A, Hicks L, Gu H, Sears DD, Ellies LG, Kalachev L, Kroll E. The Combined Treatment with Ketogenic Diet and Metformin Slows Tumor Growth in Two Mouse Models of Triple Negative Breast Cancer. RESEARCH SQUARE 2023:rs.3.rs-3664129. [PMID: 38196628 PMCID: PMC10775859 DOI: 10.21203/rs.3.rs-3664129/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Many tumors contain hypoxic microenvironments caused by inefficient tumor vascularization. Hypoxic tumors have been shown to resist conventional cancer therapies. Hypoxic cancer cells rely on glucose to meet their energetic and anabolic needs to fuel uncontrolled proliferation and metastasis. This glucose dependency is linked to a metabolic shift in response to hypoxic conditions. METHODS To leverage the glucose dependency of hypoxic tumor cells, we assessed the effects of a controlled reduction in systemic glucose by combining dietary carbohydrate restriction, using a ketogenic diet, with gluconeogenesis inhibition, using metformin, on two mouse models of triple-negative breast cancer (TNBC). RESULTS We confirmed that MET - 1 breast cancer cells require abnormally high glucose concentrations to survive in a hypoxic environment in vitro. Then, we showed that, compared to a ketogenic diet or metformin alone, animals treated with the combination regimen showed significantly lower tumor burden, higher tumor latency and slower tumor growth. As a result, lowering systemic glucose by this combined dietary and pharmacologic approach improved overall survival in our mouse model by 31 days, which is approximately equivalent to 3 human years. CONCLUSION This is the first preclinical study to demonstrate that reducing systemic glucose by combining a ketogenic diet and metformin significantly inhibits tumor proliferation and increases overall survival. Our findings suggest a possible treatment for a broad range of hypoxic and glycolytic tumor types, one that can also augment existing treatment options to improve patient outcomes.
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Affiliation(s)
- Karen Schmidt
- University of Montana Division of Biological Sciences
| | | | | | - Linda Hicks
- University of Montana Division of Biological Sciences
| | - Haiwei Gu
- Arizona State University School of Life Sciences
| | | | | | | | - Eugene Kroll
- University of Montana Missoula: University of Montana
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Lu MZ, Li DY, Wang XF. Effect of metformin use on the risk and prognosis of ovarian cancer: an updated systematic review and meta-analysis. Panminerva Med 2023; 65:351-361. [PMID: 31290300 DOI: 10.23736/s0031-0808.19.03640-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Emerging evidence suggests that metformin has a potential antitumor effect both in vitro and in vivo. Increasing epidemiological studies indicate that diabetic patients receiving metformin therapy have lower incidences of cancer and have better survival rates. However, there are limited and inconsistent studies available about the effect of metformin therapy on ovarian cancer (OC). Thus, we conducted this meta-analysis to study the effect of metformin therapy on OC. Meanwhile, we systematically reviewed relevant studies to provide a framework for future research. EVIDENCE ACQUISITION We conducted a systematic literature search on PubMed, Web of Science, Springerlink, CNKI, VIP, SinoMed, and Wanfang up to the period of October 2018. A random-effects meta-analysis model was used to derive pooled effect estimates. EVIDENCE SYNTHESIS A total of 13 studies were retrieved of which 5 studies explained the prevention and 8 studies explained the treatment for OC. Our pooled results showed that metformin has a potential preventive effect on OC in diabetic women (pooled odds ratio [OR] 0.62, 95% confidence interval [95% CI] 0.34, 1.11; P<0.001). In addition, metformin can also significantly prolong progression-free survival (PFS) (pooled hazard ratio [HR] 0.49, 95% CI 0.34, 0.70; P=0.002), and overall survival (OS) (HR 0.71, 95%CI 0.61, 0.82; P<0.001) in patients with OC, regardless of whether they had diabetes. CONCLUSIONS The use of metformin can potentially reduce the risk of OC among diabetics, and it also can significantly improve PFS and OS in patients with OC. A further large clinical investigation would be needed to adopt our finding in practice, however, our systematic review provides an insight for future study designs.
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Affiliation(s)
- Min-Zhen Lu
- Second Clinical Medical College of Southern Medical University, Guangzhou, China -
| | - De-Yu Li
- Department of Oncology, Fujian Provincial Hospital, Fujian, China
| | - Xue-Feng Wang
- Department of Obstetrics and Gynecology, Third Hospital of Southern Medical University, Guangzhou, China
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A Phase I clinical trial of dose-escalated metabolic therapy combined with concomitant radiation therapy in high-grade glioma. J Neurooncol 2021; 153:487-496. [PMID: 34152528 DOI: 10.1007/s11060-021-03786-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/08/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Animal brain-tumor models have demonstrated a synergistic interaction between radiation therapy and a ketogenic diet (KD). Metformin has in-vitro anti-cancer activity, through AMPK activation and mTOR inhibition. We hypothesized that the metabolic stress induced by a KD combined with metformin would enhance radiation's efficacy. We sought to assess the tolerability and feasibility of this approach. METHODS A single-institution phase I clinical trial. Radiotherapy was either 60 or 35 Gy over 6 or 2 weeks, for newly diagnosed and recurrent gliomas, respectively. The dietary intervention consisted of a Modified Atkins Diet (ModAD) supplemented with medium chain triglycerides (MCT). There were three cohorts: Dietary intervention alone, and dietary intervention combined with low-dose or high-dose metformin; all patients received radiotherapy. Factors associated with blood ketone levels were investigated using a mixed-model analysis. RESULTS A total of 13 patients were accrued, median age 61 years, of whom six had newly diagnosed and seven with recurrent disease. All completed radiation therapy; five patients stopped the metabolic intervention early. Metformin 850 mg three-times daily was poorly tolerated. There were no serious adverse events. Ketone levels were associated with dietary factors (ketogenic ratio, p < 0.001), use of metformin (p = 0. 02) and low insulin levels (p = 0.002). Median progression free survival was ten and four months for newly diagnosed and recurrent disease, respectively. CONCLUSIONS The intervention was well tolerated. Higher serum ketone levels were associated with both dietary intake and metformin use. The recommended phase II dose is eight weeks of a ModAD combined with 850 mg metformin twice daily.
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Abstract
PURPOSE OF REVIEW Cancer cachexia cannot be easily reversed by standard nutritional support and interventions directed at underlying metabolic derangements may be needed to prevent or reverse cachexia and maintain healthy body composition. The following review will highlight the contribution and potential therapeutic interventions for insulin resistance, alterations in ghrelin signaling, and hypogonadism in cancer patients. RECENT FINDINGS In addition to decreased caloric intake, chronic inflammation, and altered metabolism of glucose, proteins and lipids, endocrine abnormalities can propagate weight loss or changes in body composition in cancer patients. SUMMARY Cancer cachexia, loss of muscle mass with or without the loss of fat mass, is a multifactorial syndrome, which is associated with increased morbidity and mortality. Currently, limited therapeutic options for the treatment of weight loss in cancer patients exist, which lead to clinically meaningful improvements in weight gain and performance status. Treatment directed at underlying insulin resistance, low testosterone, and altered ghrelin sensitivity, in the future, may lead to potential therapeutic options for loss of lean body mass and cancer cachexia.
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Klement RJ. Wilhelm Brünings' forgotten contribution to the metabolic treatment of cancer utilizing hypoglycemia and a very low carbohydrate (ketogenic) diet. J Tradit Complement Med 2018; 9:192-200. [PMID: 31193891 PMCID: PMC6544614 DOI: 10.1016/j.jtcme.2018.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/17/2018] [Accepted: 06/20/2018] [Indexed: 12/18/2022] Open
Abstract
The growing interest in the alterations of tumor cell metabolism and their possible therapeutic exploitation also spurred new complementary and integrative approaches such as treating patients with a ketogenic diet (KD). KDs aim at inhibiting glycolytic tumor metabolism and growth, and have therefore been proposed as adjuncts not only to standard-of-care, but also to other therapies targeting tumor metabolism. Here I describe the life and forgotten work of one of the earliest researchers who realized the importance of altered tumor cell metabolism and its possible exploitation through metabolic modifications: Wilhelm Brünings. Brünings was a German natural scientist and physician famous for his innovative contributions to the fields of physiology and otorhinolaryngology. Based on the findings of Otto Warburg and his physiological reasoning he started to experiment with insulin administration and KDs in his patients with head and neck cancers, aiming to maximally lower blood glucose concentrations. He obtained encouraging short-term results, although most tumors became refractory to treatment after several weeks. His pioneering work is worth revisiting, especially for an international readership that may be unaware of his efforts, as hypoglycemic treatments, including the use of insulin injections and KDs, are currently being re-investigated as complementary and integrative cancer treatments.
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Affiliation(s)
- Rainer Johannes Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital, Robert-Koch-Str. 10, 97422, Schweinfurt, Germany
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Grabacka MM, Wilk A, Antonczyk A, Banks P, Walczyk-Tytko E, Dean M, Pierzchalska M, Reiss K. Fenofibrate Induces Ketone Body Production in Melanoma and Glioblastoma Cells. Front Endocrinol (Lausanne) 2016; 7:5. [PMID: 26869992 PMCID: PMC4735548 DOI: 10.3389/fendo.2016.00005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/14/2016] [Indexed: 11/13/2022] Open
Abstract
Ketone bodies [beta-hydroxybutyrate (bHB) and acetoacetate] are mainly produced in the liver during prolonged fasting or starvation. bHB is a very efficient energy substrate for sustaining ATP production in peripheral tissues; importantly, its consumption is preferred over glucose. However, the majority of malignant cells, particularly cancer cells of neuroectodermal origin such as glioblastoma, are not able to use ketone bodies as a source of energy. Here, we report a novel observation that fenofibrate, a synthetic peroxisome proliferator-activated receptor alpha (PPARa) agonist, induces bHB production in melanoma and glioblastoma cells, as well as in neurospheres composed of non-transformed cells. Unexpectedly, this effect is not dependent on PPARa activity or its expression level. The fenofibrate-induced ketogenesis is accompanied by growth arrest and downregulation of transketolase, but the NADP/NADPH and GSH/GSSG ratios remain unaffected. Our results reveal a new, intriguing aspect of cancer cell biology and highlight the benefits of fenofibrate as a supplement to both canonical and dietary (ketogenic) therapeutic approaches against glioblastoma.
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Affiliation(s)
- Maja M. Grabacka
- Department of Food Biotechnology, Faculty of Food Technology, University of Agriculture, Krakow, Poland
| | - Anna Wilk
- Molecular and Metabolic Oncology Program, Department of Oncologic Sciences, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA
| | - Anna Antonczyk
- Department of Food Biotechnology, Faculty of Food Technology, University of Agriculture, Krakow, Poland
| | - Paula Banks
- Department of Human Nutrition, Faculty of Food Technology, University of Agriculture, Krakow, Poland
| | - Emilia Walczyk-Tytko
- Department of Food Biotechnology, Faculty of Food Technology, University of Agriculture, Krakow, Poland
| | - Matthew Dean
- Neurological Cancer Research, Stanley S Scott Cancer Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Malgorzata Pierzchalska
- Department of Food Biotechnology, Faculty of Food Technology, University of Agriculture, Krakow, Poland
| | - Krzysztof Reiss
- Neurological Cancer Research, Stanley S Scott Cancer Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
- *Correspondence: Krzysztof Reiss,
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Hao GW, Chen YS, He DM, Wang HY, Wu GH, Zhang B. Growth of human colon cancer cells in nude mice is delayed by ketogenic diet with or without omega-3 fatty acids and medium-chain triglycerides. Asian Pac J Cancer Prev 2015; 16:2061-8. [PMID: 25773851 DOI: 10.7314/apjcp.2015.16.5.2061] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tumors are largely unable to metabolize ketone bodies for energy due to various deficiencies in one or both of the key mitochondrial enzymes, which may provide a rationale for therapeutic strategies that inhibit tumor growth by administration of a ketogenic diet with average protein but low in carbohydrates and high in fat. MATERIALS AND METHODS Thirty-six male BALB/C nude mice were injected subcutaneously with tumor cells of the colon cancer cell line HCT116. The animals were then randomly split into three feeding groups and fed either a ketogenic diet rich in omega-3 fatty acids and MCT (MKD group; n=12) or lard only (LKD group; n=12) or a standard diet (SD group; n=12) ad libitum. Experiments were ended upon attainment of the target tumor volume of 600 mm3 to 700 mm3. The three diets were compared for tumor growth and survival time (interval between tumor cell injection and attainment of target tumor volume). RESULTS The tumor growth in the MKD and LKD groups was significantly delayed compared to that in the SD group. CONCLUSIONS Application of an unrestricted ketogenic diet delayed tumor growth in a mouse xenograft model. Further studies are needed to address the mechanism of this diet intervention and the impact on other tumor-relevant parameters such as invasion and metastasis.
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Affiliation(s)
- Guang-Wei Hao
- Department General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China E-mail :
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Martuscello RT, Vedam-Mai V, McCarthy DJ, Schmoll ME, Jundi MA, Louviere CD, Griffith BG, Skinner CL, Suslov O, Deleyrolle LP, Reynolds BA. A Supplemented High-Fat Low-Carbohydrate Diet for the Treatment of Glioblastoma. Clin Cancer Res 2015; 22:2482-95. [PMID: 26631612 DOI: 10.1158/1078-0432.ccr-15-0916] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 11/12/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Dysregulated energetics coupled with uncontrolled proliferation has become a hallmark of cancer, leading to increased interest in metabolic therapies. Glioblastoma (GB) is highly malignant, very metabolically active, and typically resistant to current therapies. Dietary treatment options based on glucose deprivation have been explored using a restrictive ketogenic diet (KD), with positive anticancer reports. However, negative side effects and a lack of palatability make the KD difficult to implement in an adult population. Hence, we developed a less stringent, supplemented high-fat low-carbohydrate (sHFLC) diet that mimics the metabolic and antitumor effects of the KD, maintains a stable nutritional profile, and presents an alternative clinical option for diverse patient populations. EXPERIMENTAL DESIGN The dietary paradigm was tested in vitro and in vivo, utilizing multiple patient-derived gliomasphere lines. Cellular proliferation, clonogenic frequency, and tumor stem cell population effects were determined in vitro using the neurosphere assay (NSA). Antitumor efficacy was tested in vivo in preclinical xenograft models and mechanistic regulation via the mTOR pathway was explored. RESULTS Reducing glucose in vitro to physiologic levels, coupled with ketone supplementation, inhibits proliferation of GB cells and reduces tumor stem cell expansion. In vivo, while maintaining animal health, the sHFLC diet significantly reduces the growth of tumor cells in a subcutaneous model of tumor progression and increases survival in an orthotopic xenograft model. Dietary-mediated anticancer effects correlate with the reduction of mTOR effector expression. CONCLUSIONS We demonstrate that the sHFLC diet is a viable treatment alternative to the KD, and should be considered for clinical testing. Clin Cancer Res; 22(10); 2482-95. ©2015 AACR.
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Affiliation(s)
- Regina T Martuscello
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida. Interdisciplinary Program in Biomedical Sciences, Neuroscience, College of Medicine, University of Florida, Gainesville, Florida
| | - Vinata Vedam-Mai
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida. Center for Movement Disorders and Neuro-restoration, University of Florida, Gainesville, Florida
| | - David J McCarthy
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Michael E Schmoll
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Musa A Jundi
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Christopher D Louviere
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Benjamin G Griffith
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Colby L Skinner
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Oleg Suslov
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida
| | - Loic P Deleyrolle
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida.
| | - Brent A Reynolds
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida. Interdisciplinary Program in Biomedical Sciences, Neuroscience, College of Medicine, University of Florida, Gainesville, Florida.
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Kapelner A, Vorsanger M. Starvation of cancer via induced ketogenesis and severe hypoglycemia. Med Hypotheses 2015; 84:162-8. [DOI: 10.1016/j.mehy.2014.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 11/02/2014] [Indexed: 02/06/2023]
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Zhuang Y, Chan DK, Haugrud AB, Miskimins WK. Mechanisms by which low glucose enhances the cytotoxicity of metformin to cancer cells both in vitro and in vivo. PLoS One 2014; 9:e108444. [PMID: 25254953 PMCID: PMC4177919 DOI: 10.1371/journal.pone.0108444] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 08/29/2014] [Indexed: 11/28/2022] Open
Abstract
Different cancer cells exhibit altered sensitivity to metformin treatment. Recent studies suggest these findings may be due in part to the common cell culture practice of utilizing high glucose, and when glucose is lowered, metformin becomes increasingly cytotoxic to cancer cells. In low glucose conditions ranging from 0 to 5 mM, metformin was cytotoxic to breast cancer cell lines MCF7, MDAMB231 and SKBR3, and ovarian cancer cell lines OVCAR3, and PA-1. MDAMB231 and SKBR3 were previously shown to be resistant to metformin in normal high glucose medium. When glucose was increased to 10 mM or above, all of these cell lines become less responsive to metformin treatment. Metformin treatment significantly reduced ATP levels in cells incubated in media with low glucose (2.5 mM), high fructose (25 mM) or galactose (25 mM). Reductions in ATP levels were not observed with high glucose (25 mM). This was compensated by enhanced glycolysis through activation of AMPK when oxidative phosphorylation was inhibited by metformin. However, enhanced glycolysis was either diminished or abolished by replacing 25 mM glucose with 2.5 mM glucose, 25 mM fructose or 25 mM galactose. These findings suggest that lowering glucose potentiates metformin induced cell death by reducing metformin stimulated glycolysis. Additionally, under low glucose conditions metformin significantly decreased phosphorylation of AKT and various targets of mTOR, while phospho-AMPK was not significantly altered. Thus inhibition of mTOR signaling appears to be independent of AMPK activation. Further in vivo studies using the 4T1 breast cancer mouse model confirmed that metformin inhibition of tumor growth was enhanced when serum glucose levels were reduced via low carbohydrate ketogenic diets. The data support a model in which metformin treatment of cancer cells in low glucose medium leads to cell death by decreasing ATP production and inhibition of survival signaling pathways. The enhanced cytotoxicity of metformin against cancer cells was observed both in vitro and in vivo.
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Affiliation(s)
- Yongxian Zhuang
- Cancer Biology Research Center, Sanford Research/USD, Sioux Falls, South Dakota, United States of America
- * E-mail:
| | - Daniel K. Chan
- Sanford School of Medicine, The University of South Dakota, Vermillion, South Dakota, United States of America
| | - Allison B. Haugrud
- Cancer Biology Research Center, Sanford Research/USD, Sioux Falls, South Dakota, United States of America
| | - W. Keith Miskimins
- Cancer Biology Research Center, Sanford Research/USD, Sioux Falls, South Dakota, United States of America
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Seyfried TN, Marsh J, Shelton LM, Huysentruyt LC, Mukherjee P. Is the restricted ketogenic diet a viable alternative to the standard of care for managing malignant brain cancer? Epilepsy Res 2012; 100:310-26. [DOI: 10.1016/j.eplepsyres.2011.06.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 05/31/2011] [Accepted: 06/03/2011] [Indexed: 12/13/2022]
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