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Klement RJ. Anti-tumor effects of ketogenic diets and their synergism with other treatments in mice: Bayesian evidence synthesis of 1755 individual mouse survival data. Biomed J 2024; 47:100609. [PMID: 37245566 PMCID: PMC10900256 DOI: 10.1016/j.bj.2023.100609] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Ketogenic diets (KDs) are high-fat diets with putative anti-tumor effects. The aim of this study was to synthesize the evidence for the anti-tumor effects of KDs in mice, with a focus on their possible synergism with chemotherapy (CT), radiotherapy (RT), or targeted therapies (TT). METHODS Relevant studies were retrieved from a literature search. A total of 43 articles reporting on 65 mouse experiments fulfilled the inclusion criteria, and 1755 individual mouse survival times were collated from the study authors or the publications. The restricted mean survival time ratio (RMSTR) between the KD and control groups served as the effect size. Bayesian evidence synthesis models were used to estimate pooled effect sizes and to assess the impact of putative confounders and synergism between KD and other therapies. RESULTS Overall, there was a significant survival-prolonging effect of KD monotherapy (RMSTR = 1.161 ± 0.040), which was confirmed in meta-regression accounting for syngeneic versus xenogeneic models, early versus late KD start and subcutaneous versus other organ growth. Combining the KD with RT or TT, but not CT, was associated with a further 30% (RT) or 21% (TT) prolongation of survival. An analysis accounting for 15 individual tumor entities showed that KDs exerted significant survival-prolonging effects in pancreatic cancer (all treatment combinations), gliomas (KD + RT and KD + TT), head and neck cancer (KD + RT), and stomach cancer (KD+RT and KD + TT). CONCLUSIONS This analytical study confirmed the overall anti-tumor effects of KDs in a large number of mouse experiments and provides evidence for synergistic effects with RT and TT.
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Affiliation(s)
- Rainer J Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany.
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2
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Miller C, Austin K, Fischer L, Stringer E, Sidhu S. The Ketogenic Diet: Considerations for Cancer Survivorship. Curr Nutr Rep 2022; 11:682-694. [PMID: 36224487 DOI: 10.1007/s13668-022-00439-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW This article aims to evaluate the current practice of the ketogenic diet (KD) in oncology by discussing feasibility, impact on quality of life, and implications for dietetic practice. Articles discussed were selected based on an adult oncology population with emphasis on publications from the last 5 years. RECENT FINDINGS There is a paucity of randomized prospective trials and articles reviewed were heterogeneous in nature, limiting the ability to draw conclusions about the KDs role in cancer care and survivorship. Despite the lack of evidence, patients with cancer are interested in KD. The authors highlight barriers to supporting implementation of KD and recommend the inclusion of a registered dietitian with experience in KD to ensure safety and support the nutrition goals of patients with cancer. Thorough, well-designed randomized control trials are needed to elucidate the potential advantages of this diet therapy in cancer care and survivorship.
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Affiliation(s)
- Cara Miller
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada
| | - Karina Austin
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada
| | - Lawren Fischer
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada.
| | - Eleah Stringer
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada.,Michael Smith Health Research BC, Vancouver, Canada
| | - Satnam Sidhu
- Oncology Nutrition, BC Cancer- Victoria, 2410 Lee Ave, Victoria, BC, V8R 6V5, Canada
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3
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Feasibility and Safety of a Combined Metabolic Strategy in Glioblastoma Multiforme: A Prospective Case Series. JOURNAL OF ONCOLOGY 2022; 2022:4496734. [PMID: 36276276 PMCID: PMC9586748 DOI: 10.1155/2022/4496734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/08/2022] [Accepted: 06/28/2022] [Indexed: 11/18/2022]
Abstract
Background Glioblastoma multiforme (GBM) may be susceptible to metabolic strategies such as fasting and ketogenic diets, which lower blood glucose and elevate ketones. Combining these two strategies may be an ideal approach for sustaining a potentially therapeutic glucose ketone index (GKI). In this prospective case series, we observed whether a combined metabolic strategy was feasible, safe, and capable of sustaining a GKI <6 in patients with GBM. Methods We provided recommendations and guidelines to 10 GBM patients at various stages of tumour progression and treatment that enabled them to complete a 5–7-day fast every 1–2 months combined with a modified ketogenic diet during the intervening weeks. Patients monitored their blood glucose and ketone levels and body weight. Adverse effects were assessed. Results Patients completed a mean of 161 ± 74 days of the combined metabolic strategy, with 34 ± 18 (21%) days of prolonged fasting (mean fast duration: 6.0 ± 1.4 days) and 127 ± 59 (79%) days on the ketogenic diet. The mean GKI for all 10 patients was 3.22 (1.28 during the fasts, 5.10 during the ketogenic diet). Body weight decreased by 8.4 ± 6.9 kg (11.2% decrease in baseline weight). The most common adverse effects attributed to the fasts and ketogenic diet were fatigue, irritability, and feeling lightheaded. The metabolic strategy did not interfere with standard oncological treatments. Conclusion This is the first study to observe the feasibility and safety of repeated, prolonged fasting combined with a modified ketogenic diet in patients with GBM. Using minimal support, patients maintained the combined metabolic strategy for 5–6 months while sustaining a potentially therapeutic mean GKI of 3.22. Weight loss was considerable. Adverse effects attributed to the metabolic strategy were mild, and it did not interfere with standard oncological treatments. Study Registration: This study is registered on the Australia New Zealand Clinical Trials Registry, number ACTRN12620001310954. The study was registered on 4 December 2020.
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Amanollahi A, Khazdouz M, Malekahmadi M, Klement RJ, Lee D, Khodabakhshi A. Effect of Ketogenic Diets on Cardio-Metabolic Outcomes in Cancer Patients: A Systematic Review and Meta-Analysis of Controlled Clinical Trials. Nutr Cancer 2022; 75:95-111. [PMID: 36110060 DOI: 10.1080/01635581.2022.2117388] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In this systematic review and meta-analysis of clinical controlled trials (CCTs) we aimed to investigate the efficacy of KDs as an adjuvant therapy on cardiometabolic outcomes in patient with cancer compared to conventional non-ketogenic diets. Only CCTs involving cancer patients that were assigned to either a KD or a standard diet control group were selected. Two reviewers independently extracted the data, and a meta-analysis was performed using a random effects model to estimate weighted mean differences (WMDs) and confidence intervals (CIs) in body composition, metabolite, lipid profile, liver and kidney function parameters and quality of life. This meta-analysis showed a significant reduction in body weight (WMD= -2.99 kg; 95% CI: -4.67, -1.31; and P < 0.001), BMI (WMD= -1.08 kg/m2; 95% CI: -1.81, -0.34; P ≤ 0.002) and fat mass (WMD= -1.48 kg; 95% CI: -2.56, -0.40; and P = 0.007) by a KD. KDs significantly decreased glucose (WMD= -5.22 mg/dl; 95% CI: -9.0, -1.44; and P = 0.007), IGF-1 (WMD= -17.52 ng/ml; 95% CI: -20.24, -14.8; and P ˂0.001) and triglyceride (WMD= -24.46 mg/dl; 95% CI: -43.96, -4.95; and P = 0.014) levels. Furthermore, KDs induced ketosis by increasing β-hydroxybutyrate (WMD= 0.56 mmol/l; 95% CI: 0.37, 0.75; and P < 0.001). There were non-significant pooled effects of KDs on improving insulin, C-reactive protein and cholesterol levels and kidney and liver function. Emotional functioning was even increased significantly in the KD compared to the SD groups. In summary we found that KDs result in a greater reduction in glucose, IGF-1, triglycerides, body weight, BMI, and fat mass in cancer patients compared to traditional non-ketogenic diets and improved emotional functioning. The quality of evidence in the meta-analysis was moderate according to the Nutrigrade assessment.
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Affiliation(s)
- Alireza Amanollahi
- Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Khazdouz
- Growth and Development Research Center, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Malekahmadi
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.,Department of Clinical Nutrition, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Rainer J Klement
- Department of Radiation Oncology, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
| | - Derek Lee
- Biology Department, Boston College, Chestnut Hill, MA, USA
| | - Adeleh Khodabakhshi
- Student Research Committee, Kerman University of Medical Sciences, Kerman, Iran.,Department of Nutrition, Faculty of Public Health, Kerman University of Medical Sciences, Kerman, Iran
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5
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Muscogiuri G, Barrea L, Cantone MC, Guarnotta V, Mazzilli R, Verde L, Vetrani C, Colao A, Faggiano A. Neuroendocrine Tumors: A Comprehensive Review on Nutritional Approaches. Cancers (Basel) 2022; 14:cancers14184402. [PMID: 36139562 PMCID: PMC9496842 DOI: 10.3390/cancers14184402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Neuroendocrine neoplasms are a heterogeneous group of neoplasms with increasing incidence, high prevalence, and survival worldwide. About 90% of cases are well differentiated forms, the so-called neuroendocrine tumors (NETs), with slow proliferation rates and prolonged survival but frequent development of liver metastases and endocrine syndromes. Both the tumor itself and systemic therapy may have an impact on patient nutrition. Malnutrition has a negative impact on outcome in patients with NETs, as well as obesity. In addition, obesity and metabolic syndrome have been shown to be risk factors for both the development and prognosis of NET. Therefore, dietary assessment based on body composition and lifestyle modifications should be an integral part of the treatment of NET patients. Nutrition plans, properly formulated by a dietician, are an integral part of the multidisciplinary treatment team for patients with NETs because they allow an improvement in quality of life, providing a tailored approach based on nutritional needs and nutritional manageable signs and/or symptoms related to pharmacological treatment. The aim of this review is to condense the latest evidence on the role of the most used dietary models, the Mediterranean diet, the ketogenic diet, and intermittent fasting, in the context of NETs, while considering the clinical and molecular mechanisms by which these dietary models act.
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Affiliation(s)
- Giovanna Muscogiuri
- Centro Italiano per la cura e il Benessere del Paziente con Obesità (C.I.B.O), Unità di Endocrinologia, Dipartimento di Medicina Clinica e Chirurgia, Università Federico II, 80131 Naples, Italy
- Unità di Endocrinologia, Diabetologia ed Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università Federico II, 80131 Naples, Italy
- Cattedra Unesco “Educazione alla Salute e allo Sviluppo Sostenibile”, Università Federico II, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-0817463779; Fax: +39-081-746-3688
| | - Luigi Barrea
- Centro Italiano per la cura e il Benessere del Paziente con Obesità (C.I.B.O), Unità di Endocrinologia, Dipartimento di Medicina Clinica e Chirurgia, Università Federico II, 80131 Naples, Italy
- Dipartimento di Scienze Umanistiche, Università Telematica Pegaso, Via Porzio, Centro Direzionale, Isola F2, 80143 Naples, Italy
| | - Maria Celeste Cantone
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), University of Milan, 20157 Milan, Italy
| | - Valentina Guarnotta
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, 90127 Palermo, Italy
| | - Rossella Mazzilli
- Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy
| | - Ludovica Verde
- Centro Italiano per la cura e il Benessere del Paziente con Obesità (C.I.B.O), Unità di Endocrinologia, Dipartimento di Medicina Clinica e Chirurgia, Università Federico II, 80131 Naples, Italy
| | - Claudia Vetrani
- Unità di Endocrinologia, Diabetologia ed Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università Federico II, 80131 Naples, Italy
- Cattedra Unesco “Educazione alla Salute e allo Sviluppo Sostenibile”, Università Federico II, 80131 Naples, Italy
| | - Annamaria Colao
- Centro Italiano per la cura e il Benessere del Paziente con Obesità (C.I.B.O), Unità di Endocrinologia, Dipartimento di Medicina Clinica e Chirurgia, Università Federico II, 80131 Naples, Italy
- Unità di Endocrinologia, Diabetologia ed Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università Federico II, 80131 Naples, Italy
- Cattedra Unesco “Educazione alla Salute e allo Sviluppo Sostenibile”, Università Federico II, 80131 Naples, Italy
| | - Antongiulio Faggiano
- Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy
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6
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Evangeliou AE, Spilioti MG, Vassilakou D, Goutsaridou F, Seyfried TN. Restricted Ketogenic Diet Therapy for Primary Lung Cancer With Metastasis to the Brain: A Case Report. Cureus 2022; 14:e27603. [PMID: 36059366 PMCID: PMC9435310 DOI: 10.7759/cureus.27603] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 11/05/2022] Open
Abstract
A high-fat and low-carbohydrate diet was administered as a complementary and alternative therapy to a 54-year-old man suffering from non-small-cell lung cancer (NSCLC) with brain metastasis. Three months after the cessation of chemotherapy and radiotherapy, a ketogenic diet (KD) was initiated. This approach was an attempt to stabilize the disease progression after chemotherapy and radiotherapy. Computed tomography following radiation and chemotherapy showed a reduction in the right frontal lobe lesion from 5.5 cm × 6.2 cm to 4 cm × 2.7 cm, while the mass in the upper-right lung lobe reduced from 6.0 cm × 3.0 cm to 2.0 × 1.8 cm. Two years after KD initiation and without any other therapeutic intervention, the right frontal lobe lesion calcified and decreased in size to 1.9 cm × 1.0 cm, while the size of the lung mass further decreased to 1.7 cm × 1.0 cm. The size of the brain and lung lesion remained stable after nine years of KD therapy. However, dyslipidemia developed after this time which led to the discontinuation of the diet. No tumor relapse or health issues occurred for two years after the discontinuation of the diet. This case report indicates that the inclusion of ketogenic metabolic therapy following radiation and chemotherapy is associated with better clinical and survival outcomes for our patient with metastatic NSCLC.
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7
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Biard L, Bergeron A, Lévy V, Chevret S. Bayesian survival analysis for early detection of treatment effects in phase 3 clinical trials. Contemp Clin Trials Commun 2021; 21:100709. [PMID: 33511301 PMCID: PMC7817368 DOI: 10.1016/j.conctc.2021.100709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/04/2020] [Accepted: 01/04/2021] [Indexed: 11/26/2022] Open
Abstract
Despite appealing characteristics for the clinical trials setting, Bayesian inference methods remain scarcely used, especially in randomized controlled clinical trials (RCT). This is particularly true when dealing with a survival endpoint, likely due to the additional complexities to model specifications. We propose to use Bayesian inference to estimate the treatment effect in this setting, using a proportional hazards (PH) model for right-censored data. Implementation of such an estimation process is illustrated on two working examples from cancer RCTs, the ALLOZITHRO and the CLL7-SA trials, both originally analyzed using a frequentist approach. In these two different settings, we show that Bayesian sequential analyses can provide early insight on treatment effect in RCTs. Relying on posterior distributions and predictive posterior probabilities, we find that Bayesian sequential analyses of the ALLOZITHRO trial, which was terminated early due to an unanticipated deleterious effect of the intervention on survival, allow quantifying early that the treatment effect was opposite to what was expected. Then, incorporating historical data in the sequential analyses of the CLL7-SA trial would have allowed the treatment effect to be closer to the protocol hypothesis. These post-hoc results give grounds to advocate for a wider use of Bayesian approaches in RCTs, including those with right-censored endpoints, as informative decision tools.
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Affiliation(s)
- Lucie Biard
- INSERM U1153, Team ECSTRRA, Hôpital Saint Louis, 1 avenue Claude Vellefaux, 75010 Paris, France
- Université de Paris, Paris, France
- AP-HP Hôpital Saint Louis, Service de Biostatistique et Information Médicale, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Anne Bergeron
- INSERM U1153, Team ECSTRRA, Hôpital Saint Louis, 1 avenue Claude Vellefaux, 75010 Paris, France
- Université de Paris, Paris, France
- AP-HP Hôpital Saint Louis, Service de Pneumologie, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Vincent Lévy
- INSERM U1153, Team ECSTRRA, Hôpital Saint Louis, 1 avenue Claude Vellefaux, 75010 Paris, France
- Université Paris 13, France
- AP-HP Hôpital Avicenne, Unité de Recherche Clinique Bobigny, France
| | - Sylvie Chevret
- INSERM U1153, Team ECSTRRA, Hôpital Saint Louis, 1 avenue Claude Vellefaux, 75010 Paris, France
- Université de Paris, Paris, France
- AP-HP Hôpital Saint Louis, Service de Biostatistique et Information Médicale, 1 avenue Claude Vellefaux, 75010, Paris, France
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8
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Muscogiuri G, Barrea L, Campolo F, Sbardella E, Sciammarella C, Tarsitano MG, Bottiglieri F, Colao A, Faggiano A. Ketogenic diet: a tool for the management of neuroendocrine neoplasms? Crit Rev Food Sci Nutr 2020; 62:1035-1045. [PMID: 33938778 DOI: 10.1080/10408398.2020.1832955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Neuroendocrine neoplasms (NENs) are a heterogeneous group of neoplasms, whose incidence has rapidly increased in the last years. Nutrition plays an important role in their management; indeed, malnutrition negatively impacts on rates of complications, hospitalization, hospital stay, costs and mortality. Furthermore, it has been reported that a poor nutritional status could influence the outcome of patients with pancreatic NENs. Moreover, obesity, predisposing to insulin resistance and compensatory hyperinsulinemia, could stimulate the growth of these neoplasms. Ketogenic diet (KD), a high-fat, low-carbohydrate diet with adequate amounts of protein, has been reported to be a promising approach for the management of several types of cancer, mostly gynecological and neurological ones. Indeed, it appears to sensitize most cancers to standard treatment by exploiting the reprogramed metabolism of cancer cells and thus resulting in a promising candidate as an adjuvant cancer therapy. Thus, the aim of this review is to provide an overview on the importance of nutrition in cancer management and in particular in NENs' setting. Furthermore, we reported the current evidence on the efficacy of KD in the management of cancer and based on molecular mechanisms; we also hypothesize the potential use of this nutritional pattern in the management of NENs.
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Affiliation(s)
- Giovanna Muscogiuri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.,Centro Italiano per la cura e il Benessere del paziente con Obesità (C.I.B.O), Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Luigi Barrea
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.,Centro Italiano per la cura e il Benessere del paziente con Obesità (C.I.B.O), Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Federica Campolo
- Department of Experimental Medicine, University of Rome "La Sapienza," Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, University of Rome "La Sapienza," Rome, Italy
| | - Concetta Sciammarella
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | | | - Filomena Bottiglieri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.,Centro Italiano per la cura e il Benessere del paziente con Obesità (C.I.B.O), Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.,UNESCO Chair "Education for Health and Sustainable Development," Federico II University, Naples, Italy
| | - Antongiulio Faggiano
- Department of Experimental Medicine, University of Rome "La Sapienza," Rome, Italy
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9
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Khodabakhshi A, Akbari ME, Mirzaei HR, Seyfried TN, Kalamian M, Davoodi SH. Effects of Ketogenic metabolic therapy on patients with breast cancer: A randomized controlled clinical trial. Clin Nutr 2020; 40:751-758. [PMID: 32703721 DOI: 10.1016/j.clnu.2020.06.028] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/15/2020] [Accepted: 06/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ketogenic metabolic therapy (KMT) using ketogenic diets (KD) is emerging as viable alternative or complementary strategy for managing cancer; however, few clinical trials have been reported. The present study aimed to evaluate the effects of a KD in patients with locally advanced and metastatic breast cancer receiving chemotherapy. METHODS A total of 80 patients undergoing treatment with chemotherapy were randomly assigned to KD or control group for 12 weeks. Concurrent with the admission, midway point, and at 12 weeks, fasting blood samples were collected for evaluation of insulin, IGF-1, CEA, CA15-3, ESR, CRP, IL-10, and TNF-α. Sonography for patients with locally advanced disease and CT or MRI scans for patients with metastatic disease were done on admission and at 12 weeks. At the completion of the chemotherapy, patients with locally advanced disease underwent surgery and stage was recalculated. Also patients with metastases were evaluated for response rate. RESULTS TNF-α decreased significantly after 12 weeks of treatment (MD: 0.64 [CI 95%: -3.7, 5] P < 0.001), while IL-10 increased (MD: 0.95 [CI 95%: -1,3] P < 0.001) in the intervention compared to the control group. Patients in the KD group had lower adjusted serum insulin compared to the control group (MD:-1.1 [CI 95%: -3,1] p < 0.002). KD lead to a reduction in tumor size in the KD compared to the control (27 vs 6 mm, P = 0.01). Stage decreased significantly in patients with locally advanced disease in the KD group after 12 weeks (P < 0.01). No significant differences in response rate were observed in patients with metastatic disease. CONCLUSIONS KMT in breast cancer patients might exert beneficial effects through decreasing TNF-α and insulin and increasing IL-10. KD may result in a better response through reductions in tumor size and downstaging in patients with locally advanced disease; however, more studies are needed to elucidate the potential beneficial effects of KD in patients with metastases. TRIAL REGISTRATION This trial has been registered on Iranian Registry of Clinical Trials (IRCT) under the identification code: IRCT20171105037259N2. https://www.irct.ir/trial/30755.
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Affiliation(s)
- Adeleh Khodabakhshi
- Department of Nutrition, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran; Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Hamid Reza Mirzaei
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Thomas N Seyfried
- Department of Biology, Boston College, Chestnut Hill, MA, United States
| | | | - Sayed Hossein Davoodi
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Cellular and Molecular Nutrition, Faculty of Nutrition Science and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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10
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Seyfried TN, Mukherjee P, Iyikesici MS, Slocum A, Kalamian M, Spinosa JP, Chinopoulos C. Consideration of Ketogenic Metabolic Therapy as a Complementary or Alternative Approach for Managing Breast Cancer. Front Nutr 2020; 7:21. [PMID: 32219096 PMCID: PMC7078107 DOI: 10.3389/fnut.2020.00021] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/21/2020] [Indexed: 12/14/2022] Open
Abstract
Breast cancer remains as a significant cause of morbidity and mortality in women. Ultrastructural and biochemical evidence from breast biopsy tissue and cancer cells shows mitochondrial abnormalities that are incompatible with energy production through oxidative phosphorylation (OxPhos). Consequently, breast cancer, like most cancers, will become more reliant on substrate level phosphorylation (fermentation) than on oxidative phosphorylation (OxPhos) for growth consistent with the mitochondrial metabolic theory of cancer. Glucose and glutamine are the prime fermentable fuels that underlie therapy resistance and drive breast cancer growth through substrate level phosphorylation (SLP) in both the cytoplasm (Warburg effect) and the mitochondria (Q-effect), respectively. Emerging evidence indicates that ketogenic metabolic therapy (KMT) can reduce glucose availability to tumor cells while simultaneously elevating ketone bodies, a non-fermentable metabolic fuel. It is suggested that KMT would be most effective when used together with glutamine targeting. Information is reviewed for suggesting how KMT could reduce systemic inflammation and target tumor cells without causing damage to normal cells. Implementation of KMT in the clinic could improve progression free and overall survival for patients with breast cancer.
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Affiliation(s)
| | - Purna Mukherjee
- Biology Department, Boston College, Chestnut Hill, MA, United States
| | - Mehmet S. Iyikesici
- Medical Oncology, Kemerburgaz University Bahcelievler Medical Park Hospital, Istanbul, Turkey
| | - Abdul Slocum
- Medical Oncology, Chemo Thermia Oncology Center, Istanbul, Turkey
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11
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Ketogenic diets in medical oncology: a systematic review with focus on clinical outcomes. Med Oncol 2020; 37:14. [PMID: 31927631 DOI: 10.1007/s12032-020-1337-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/02/2020] [Indexed: 12/30/2022]
Abstract
Preclinical data provide evidence for synergism between ketogenic diets (KDs) and other oncological therapies. The aim of this systematic review was to summarize data from clinical studies that have tested KDs along with other treatments used within medical oncology. The PubMed database was searched using the key words "ketogenic" AND ("cancer" OR "glioblastoma"). A secondary search was conducted by screening the reference lists of relevant articles on this topic. Relevant studies for this review were defined as studies in which KDs were used complementary to surgery, radio-, chemo-, or targeted therapy and at least one of the following four outcomes were reported: (i) Overall survival (OS); (ii) progression-free survival (PFS); (iii) local control rate; (iv) body composition changes. Twelve papers reporting on 13 clinical studies were identified. Nine studies were prospective and six had a control group, but only two were randomized. KD prescription varied widely between studies and was described only rudimentarily in most papers. Adverse events attributed to the diet were rare and only minor (grade 1-2) except for one possibly diet-related grade 4 event. Studies reporting body composition changes found beneficial effects of KDs in both overweight and frail patient populations. Beneficial effects of KDs on OS and/or PFS were found in four studies including one randomized controlled trial. Studies in high-grade glioma patients were not sufficiently powered to prove efficacy. Evidence for beneficial effects of KDs during cancer therapy is accumulating, but more high-quality studies are needed to assess the overall strength of evidence.
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12
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Ji CC, Hu YY, Cheng G, Liang L, Gao B, Ren YP, Liu JT, Cao XL, Zheng MH, Li SZ, Wan F, Han H, Fei Z. A ketogenic diet attenuates proliferation and stemness of glioma stem‑like cells by altering metabolism resulting in increased ROS production. Int J Oncol 2019; 56:606-617. [PMID: 31894296 DOI: 10.3892/ijo.2019.4942] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 10/01/2019] [Indexed: 11/05/2022] Open
Abstract
Abnormal metabolism serves a critical role in the development and progression of different types of malignancies including glioblastoma (GBM), and may therefore serve as a promising target for treatment of cancer. Preclinical studies have indicated that a ketogenic diet (KD) may exhibit beneficial effects in patients with GBM; however, the underlying mechanisms remain incompletely understood. The aim of the present study was to evaluate the effects of a KD on glioma stem‑like cells (GSCs), by culturing patient‑derived primary GSCs as well as a GSC cell line in glucose‑restricted, β‑hydroxybutyrate‑containing medium (BHB‑Glow) which was used to mimic clinical KD treatment. GSCs cultured in BHB‑Glow medium exhibited reduced proliferation and increased apoptosis compared with cells grown in the control medium. Furthermore, decreased expression of stem cell markers, diminished self‑renewal in vitro, and reduced tumorigenic capacity in vivo, providing evidence that the stemness of GSCs was compromised. Mechanistically, culturing in BHB‑Glow medium reduced glucose uptake and inhibited glycolysis in GSCs. Furthermore, culturing in the BHB‑Glow medium resulted in morphological and functional disturbances to the mitochondria of GSCs. These metabolic changes may have reduced ATP production, promoted lactic acid accumulation, and thus, increased the production of reactive oxygen species (ROS) in GSCs. The expression levels and activation of mammalian target of rapamycin, hypoxia‑inducible factor 1 and B‑cell lymphoma 2 were decreased, consistent with the reduced proliferation of GSCs in BHB‑Glow medium. ROS scavenging reversed the inhibitory effects of a KD on GSCs. Taken together, the results demonstrate that treatment with KD inhibited proliferation of GSCs, increased apoptosis and attenuated the stemness in GSCs by increasing ROS production.
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Affiliation(s)
- Chen-Chen Ji
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Yi-Yang Hu
- State Key Laboratory of Cancer Biology, Department of Medical Genetics and Developmental Biology, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Guang Cheng
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Liang Liang
- State Key Laboratory of Cancer Biology, Department of Medical Genetics and Developmental Biology, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Bo Gao
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Ying-Peng Ren
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Jin-Tao Liu
- Department of Orthopedic Surgery, 413 Hospital, Zhoushan, Zhejiang 316000, P.R. China
| | - Xiu-Li Cao
- State Key Laboratory of Cancer Biology, Department of Medical Genetics and Developmental Biology, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Min-Hua Zheng
- State Key Laboratory of Cancer Biology, Department of Medical Genetics and Developmental Biology, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - San-Zhong Li
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Feng Wan
- Department of Neurosurgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Hua Han
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Zhou Fei
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
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Complementary and alternative medicine use in glioma patients in France. J Neurooncol 2019; 145:487-499. [DOI: 10.1007/s11060-019-03315-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 10/03/2019] [Indexed: 12/21/2022]
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14
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Klement RJ, Sweeney RA, Gross EC, Champ CE. Problems associated with a highly artificial ketogenic diet: Letter to the Editor Re: van der Louw EJTM, Olieman JF, van den Bemt PMLA, et al. 'Ketogenic diet treatment as adjuvant to standard treatment of glioblastoma multiforme: a feasibility and safety study'. Ther Adv Med Oncol 2019; 11:1758835919879268. [PMID: 31662797 PMCID: PMC6792271 DOI: 10.1177/1758835919879268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Reinhart A. Sweeney
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
| | | | - Colin E. Champ
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abstract
In his book “Medical Philosophy: Conceptual issues in Medicine”, Mario Bunge provides a unique account of medical philosophy that is deeply rooted in a realist ontology he calls “systemism”. According to systemism, the world consists of systems and their parts, and systems possess emergent properties that their parts lack. Events within systems may form causes and effects that are constantly conjoined via particular mechanisms. Bunge supports the views of the evidence-based medicine movement that randomized controlled trials (RCTs) provide the best evidence to establish the truth of causal hypothesis; in fact, he argues that only RCTs have this ability. Here, we argue that Bunge neglects the important feature of patients being open systems which are in steady interaction with their environment. We show that accepting this feature leads to counter-intuitive consequences for his account of medical hypothesis testing. In particular, we point out that (i) the confirmation of hypotheses is inherently stochastic and affords a probabilistic account of both confirmation and evidence which we provide here; (ii) RCTs are neither necessary nor sufficient to establish the truth of a causal claim; (iii) testing of causal hypotheses requires taking into account background knowledge and the context within which an intervention is applied. We conclude that there is no “best” research methodology in medicine, but that different methodologies should coexist in a complementary fashion.
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Seyfried TN, Shelton L, Arismendi-Morillo G, Kalamian M, Elsakka A, Maroon J, Mukherjee P. Provocative Question: Should Ketogenic Metabolic Therapy Become the Standard of Care for Glioblastoma? Neurochem Res 2019; 44:2392-2404. [PMID: 31025151 DOI: 10.1007/s11064-019-02795-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 12/20/2022]
Abstract
No major advances have been made in improving overall survival for glioblastoma (GBM) in almost 100 years. The current standard of care (SOC) for GBM involves immediate surgical resection followed by radiotherapy with concomitant temozolomide chemotherapy. Corticosteroid (dexamethasone) is often prescribed to GBM patients to reduce tumor edema and inflammation. The SOC disrupts the glutamate-glutamine cycle thus increasing availability of glucose and glutamine in the tumor microenvironment. Glucose and glutamine are the prime fermentable fuels that underlie therapy resistance and drive GBM growth through substrate level phosphorylation in the cytoplasm and the mitochondria, respectively. Emerging evidence indicates that ketogenic metabolic therapy (KMT) can reduce glucose availability while elevating ketone bodies that are neuroprotective and non-fermentable. Information is presented from preclinical and case report studies showing how KMT could target tumor cells without causing neurochemical damage thus improving progression free and overall survival for patients with GBM.
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Affiliation(s)
- Thomas N Seyfried
- Biology Department, Boston College, 140 Commonwealth Ave, Chestnut Hill, MA, 02467, USA.
| | - Laura Shelton
- Human Metabolome Technologies America, 24 Denby Rd., Boston, MA, 02134, USA
| | - Gabriel Arismendi-Morillo
- Instituto de Investigaciones Biológicas, Facultad de Medicina, Universidad del Zulia, Maracaibo, 526, Venezuela
| | | | - Ahmed Elsakka
- Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Joseph Maroon
- Department of Neurosurgery, University of Pittsburgh Medical Center, Suite 5C, 200 Lothrop St., Pittsburgh, PA, USA
| | - Purna Mukherjee
- Biology Department, Boston College, 140 Commonwealth Ave, Chestnut Hill, MA, 02467, USA
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Xu T, Yu W, Li Q, Li X, Shi Y, Cao B, Zhang Y, Wang S, Zhang Y, Wang T, Huang B. MicroRNA-524 inhibits the progress of glioma via the direct targeting of NCF2. Am J Transl Res 2019; 11:1605-1615. [PMID: 30972186 PMCID: PMC6456563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/09/2019] [Indexed: 06/09/2023]
Abstract
In recent years, a large amount of research has reported that microRNA (miRNA) dysregulation is closely related to glioma progression. miR-524, a member of the miRNA family, has been confirmed to be involved in many human diseases, including glioma. However, the role and molecular mechanism of miR-524 in glioma have not been clarified. In our study, we showed that miR-524 expression was significantly decreased in glioma and was associated with glioma recurrence. Next, we performed a series of assays and confirmed that the upregulation of miR-524 suppressed glucose uptake, proliferation, migration and invasion in glioma cell lines. Then, through bioinformatics software and a dual luciferase assay, we demonstrated that NCF2 was a target gene of miR-524. In addition, we found that NCF2 reintroduction restored the inhibitor effect of miR-524 on glioma progression. These results elucidate the mechanism of miR-524 in glioma development and provide a potential therapeutic strategy for glioma patients.
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Affiliation(s)
- Tuoye Xu
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical UniversityNanjing, Jiangsu Province, China
| | - Wan Yu
- Department of Neurosurgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese MedicineNanjing, Jiangsu Province, China
| | - Qingquan Li
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
| | - Xiaojian Li
- Department of Neurosurgery, Nanjing First Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
| | - Yan Shi
- Department of Neurosurgery, Nanjing First Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
| | - Boqiang Cao
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
| | - Yaxuan Zhang
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
| | - Seng Wang
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
| | - Yan Zhang
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
| | - Tianlu Wang
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
| | - Baosheng Huang
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical UniversityNanjing, Jiangsu Province, China
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Abstract
PURPOSE OF REVIEW Altered glucose metabolism in cancer cells is an almost ubiquitous observation, yet hardly exploited therapeutically. However, ketogenic diets have gained growing attention in recent years as a nontoxic broad-spectrum approach to target this major metabolic difference between normal and cancer cells. Although much research still needs to be done, new knowledge has been gained about the optimal utilization of ketogenic diets for cancer treatment that this review aims to summarize. RECENT FINDINGS Although most preclinical studies indicate a therapeutic potential for ketogenic diets in cancer treatment, it is now becoming clear that not all tumors might respond positively. Early clinical trials have investigated ketogenic diets as a monotherapy and - while showing the safety of the approach even in advanced cancer patients - largely failed to prove survival prolonging effects. However, it gradually became clear that the greatest potential for ketogenic diets is as adjuvant treatments combined with pro-oxidative or targeted therapies initiated in early stages of the disease. Beneficial effects on body composition and quality of life have also been found. SUMMARY Ketogenic diets against cancer are worth further exploration, both in the laboratory and clinically. Patients wishing to undertake a ketogenic diet during therapy should receive dietary counselling to avoid common mistakes and optimize compliance. Future research should focus more on important clinical endpoints.
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Affiliation(s)
- Rainer Johannes Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
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19
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Ghaffari H, Varner JD, Petzold LR. Analysis of the role of thrombomodulin in all-trans retinoic acid treatment of coagulation disorders in cancer patients. Theor Biol Med Model 2019; 16:3. [PMID: 30764845 PMCID: PMC6376718 DOI: 10.1186/s12976-019-0099-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 01/24/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clinical studies have shown that all-trans retinoic acid (RA), which is often used in treatment of cancer patients, improves hemostatic parameters and bleeding complications such as disseminated intravascular coagulation (DIC). However, the mechanisms underlying this improvement have yet to be elucidated. In vitro studies have reported that RA upregulates thrombomodulin (TM) expression on the endothelial cell surface. The objective of this study was to investigate how and to what extent the TM concentration changes after RA treatment in cancer patients, and how this variation influences the blood coagulation cascade. RESULTS In this study, we introduced an ordinary differential equation (ODE) model of gene expression for the RA-induced upregulation of TM concentration. Coupling the gene expression model with a two-compartment pharmacokinetic model of RA, we obtained the time-dependent changes in TM and thrombomodulin-mRNA (TMR) concentrations following oral administration of RA. Our results indicated that the TM concentration reached its peak level almost 14 h after taking a single oral dose (110 [Formula: see text]) of RA. Continuous treatment with RA resulted in oscillatory expression of TM on the endothelial cell surface. We then coupled the gene expression model with a mechanistic model of the coagulation cascade, and showed that the elevated levels of TM over the course of RA therapy with a single daily oral dose (110 [Formula: see text]) of RA, reduced the peak thrombin levels and endogenous thrombin potential (ETP) up to 50 and 49%, respectively. We showed that progressive reductions in plasma levels of RA, observed in continuous RA therapy with a once-daily oral dose (110 [Formula: see text]) of RA, did not affect TM-mediated reduction of thrombin generation significantly. This finding prompts the hypothesis that continuous RA treatment has more consistent therapeutic effects on coagulation disorders than on cancer. CONCLUSIONS Our results indicate that the oscillatory upregulation of TM expression on the endothelial cells over the course of RA therapy could potentially contribute to the treatment of coagulation abnormalities in cancer patients. Further studies on the impacts of RA therapy on the procoagulant activity of cancer cells are needed to better elucidate the mechanisms by which RA therapy improves hemostatic abnormalities in cancer.
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Affiliation(s)
- Hamed Ghaffari
- Department of Mechanical Engineering, University of California Santa Barbara, Santa Barbara, CA, 93106, USA.
| | - Jeffrey D Varner
- School of Chemical and Biomolecular Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Linda R Petzold
- Department of Mechanical Engineering, University of California Santa Barbara, Santa Barbara, CA, 93106, USA.,Department of Computer Science, University of California Santa Barbara, Santa Barbara, CA, 93106, USA
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