Why Isn’t Nutritional Therapy a Standard Part of Cancer Treatment?
The talk below was given by Suzannah Olivier at the 2000 annual cancer conference on integrated care organised by New Approaches to Cancer. The conference was attended by health care professionals from both traditional and complementary medicine, and talks were given by a number of speakers including Professor Karol Sikora of Charing Cross Hospital and a leading expert on cancer care.
© Suzannah Olivier, 2000

Ideally we would be talking about prevention of cancer and indeed there is a strong movement towards improving awareness in this area (Food Nutrition and the Prevention of Cancer: A Global Perspective 1997). This World Cancer Research Fund publication says that addressing diet and exercise would accounts for up to a 40 per cent reduction in cancer, and "The two most important ways to reduce cancer risk are the avoidance of cancer causing agents (ie smoking)… and the habitual consumption of diets high in foods and drinks that protect against cancer". According to the World Health Organisation we are exporting our cancer risks to developing countries by exporting our smoking and dietary habits. But the reality is that people don’t say "I’m feeling terrific today, I think I’ll check out my risk of developing cancer". Most people do not think about cancer, most of the time, until it hits them, and hence the need for this conference, and this talk.

I feel a little like Professor Higgins (the Rex Harrison character) in My Fair Lady asking ‘Why can’t a woman be more like a man?’. It was, of course, an absurd question at that time, but now we’ve had social changes which encourage equality which has brought about many changes. Equally the question ‘Why isn’t nutritional therapy a standard part of cancer treatment?’ would have been absurd only a few years ago, but now the fact that a conference such as this is being organised, and I am invited to stand here and at least ask the question, is a sign that the climate is changing.

There are a few issues that need to be examined if we are to begin to answer this question.

• What is nutritional therapy?
• Do cancer patients want nutritional therapy?
• What is the evidence for nutritional manipulation making a difference to cancer patient outcomes?

There are many other questions, but half an hour does not begin to let me address them, however I hope that what I am able to cover is food for thought, and for healing. Lets look at these questions in turn:

What is nutritional therapy and how does it differ from hospital dietetics in the management of cancer patients?
 
I will use the definition outlined in the Royal Marsden’s publication (Coping With Cancer at Home 2000) – both because it is useful to hear a definition used by a hospital, and also because I broadly agree with it. They say:

" Cancer treatments such as chemotherapy and radiotherapy can have a major
effect on appetite and weight loss. Hospital dieticians can help to minimise
these side effects by advising on diets and nutritional supplements that
provide support throughout treatment. Nutritional therapists focus more on
using diet as part of the healing process and with cancer, the emphasis is on
boosting the immune system" (my emphasis).

I would add that nutritional therapists will use diet, but are also quite likely to use supplements alongside dietary changes. While I am mentioning individual nutrients and supplements in this talk, I would like to make the point that diet always comes first, and is of greater importance.
Supplements do have their place, however, and are likely to be of therapeutic value as is discussed later.

Other possible influences of nutritional therapy, apart from boosting the immune system, might be:
• To improve healing potential after surgery, by helping repair of tissues.
• To ensure digestive health to maximise the absorption of nutrients from the diet.
• To influence the balance of hormones in the case of hormone dependent cancers (ie breast, prostate)
• To assist the mental sphere by having an impact on moods at a biochemical level. Also of importance is the self-empowerment that comes when a patient is able to help themselves.
• To encourage conditions which are hostile to malignant tumour promotion (principally supporting the immune system, but also ensuring health at a cellular level – ie gene expression, cell membrane integrity).

My definition of nutritional intervention is:

1) To encourage healthy eating guidelines.
2) Focus on the individual’s health strengths and weaknesses (this is a critical aspect of individual, tailored, nutritional intervention).
3) Make specific recommendations using foods, and possibly vitamin and mineral supplements, for their therapeutic effects.
Nutrition also needs to be presented in a way that is nurturing and enjoyable, and not stressful.

Nutrition is considered an interventionist treatment

One of the major obstacles that nutritional therapy is having to overcome is that it is not viewed in quite the same way as other contenders for integrated cancer care. It sits on the fence between complementary medicine and orthodox medicine. To put it bluntly, you have to face it that doctors are quite likely to be happy to have their patients’ feet twiddled, or for them to be massaged with essential oils, because while some believe that disciplines such as reflexology or aromatherapy may confer benefit, a significant number will also be of the opinion that even if they are sceptical about the benefits they at least believe these treatments will do no harm as they are non-interventionist.

But there is more caution about the use of nutrition. Nutrition is a science, which means it is viewed in a different way to the hands-on therapies. First of all many doctors are cautious about the potential to do harm. Secondly there is a requirement for nutrition to prove itself in trials. I will return to this these themes later.

According to the British Nutrition Foundation "There is a nutritional component to most illnesses, and therefore all medical disciplines are involved. It is estimated that 70 per cent of malnutrition in the UK goes unrecognised and untreated". (Shenker. 2000). The 1994 MAFF report concluded that the percentage of people who are deficient in the recommended nutrient intakes (RNIs) are as follows:

(Gregory et al 1990).

In my estimation this malnutrition must have an impact on the risk, not only of cancer, but also on the recurrence of cancer for a significant number of patients.

Do cancer patients want nutritional therapy?

I think that we have to accept that cancer patients are using nutritional therapy anyway, either under the professional guidance of a nutritionist, or under their own steam by reading books and gathering other information. One USA study found that over 80 per cent of women were reporting that they used supplements after being diagnosed with breast cancer. (Newman et al. 1998).

The huge interest in complementary medicine is being spearheaded at a grass roots level. On the plus side this is pushing the discipline to the forefront of consciousness about how to best help cancer patients. However, it is probably ideal that cancer patients should have professional advice about what is likely to be the best way to proceed with nutrition, and the right environment for this is probably under the umbrella of integrated care at a hospital treatment centre. This is in line with the current climate of informed choice for patients, but also gives the cancer specialists the opportunity to gage the efficacy of nutritional intervention. This is also in line with the recommendations of the House of Lords report on Complementary and Alternative Medicine (2000) in which they discuss the need for trials within the orthodox medicine setting.

I suspect that a proportion of cancer specialists would welcome a move to provide more formal help for patients with nutritional information, because they are being bombarded with questions from patients which cause them some problems:

• Specialists, registrars and nurses receive little nutritional training of any substance and this means that they are unable to adequately answer their patients’ many questions.
• There is growing sympathy amongst the medical profession for the logic of, and the use of, nutritional therapy. Indeed it is not unusual to find specialists who use nutritional strategies for their own health, even though they ‘officially’ cannot recommend it.
• Some specialist will voice the opinion that ‘there is no evidence that
nutritional therapy makes a difference to cancer patient health outcome’. BUT this is not the same as saying that changing diet will not make a difference, only that the research has not been done (as opposed to the vast body of research regarding nutrition and cancer aetiology). There is only one way to find out if nutrition makes a difference to patient outcome and that is to run trials.

What is the evidence for nutritional manipulation making a difference to patient outcomes?

Improved patient outcomes mean:

• Improved overall health/ quality of life
• Better toleration of hospital treatments (surgery, chemo, etc)
• Improved longevity – the holy grail

Several thousand papers are now available regarding nutrition and cancer. A search of the database at Bristol Cancer Help Centre will reveal at least 4000 paper. In total there are many more than this and more are being peer reviewed weekly.

Unfortunately nutrition is the poor cousin of research, as outlined to me in personal discussions with the medical fraternity. One Professor who heads up an oncology department in a major teaching hospital and who is doing some excellent research on the effects of fish oils and prostate cancer commented to me, a few weeks ago, that if he was seeing the results he has achieved in
early trials with a drug therapy, it would be front page news and the drug companies would be clamouring to get on board. Yet, because nutrition research is the ‘poor relative’ of research finding funding for the next stage of trials would, as ever, be a bit of an uphill battle. A degree of frustration was also expressed to me a couple of months ago by another Professor heading up a large cancer centre. He is seeing what he thinks are important results with regard to soya isoflavones and prostate cancer, and believes that we need to see this information being used in a practical way.

The question of improved outcome for cancer patients using nutritional intervention alongside conventional treatment is a sketchy area at the moment and we are only just beginning to build a picture assessing the benefits.
There have been no substantial investigations into the question. However we can get clues from several places about whether nutritional intervention will actually help patients diagnosed with cancer to feel better and to live longer.

My first point does not involve cancer at all, but is an indication that nutritional intervention can improve the prognosis for a serious disease state. The results of a recent study were presented at the American Heart Association’s annual conference this year. The study involved 12,000 patients who had had heart attack within three months of the comencement of the study, and found that those who ate more fruit, vegetables, olive oil and fish did considerably better over the 3.5 years of the study, than those who ate butter and other vegetable oils. One gram of supplemented n-3 polyunsaturated fish oils daily lowered the risk of death by 20 per cent ( Machioli et al. 2000).

The point I am making is that it is common for those with heart attacks to be told to change their diet to that of the Mediterranean diet. It is always the case that those with diabetes are asked to adopt the type of diet that would also prevent the disease. However the cancer patient who asks if they should adapt their diet will almost invariably be told to ‘eat normally’. Of course, no indication of how to eat normally is given, and what is normal for one person may be different to that of the next person. We need to see
some large scales studies, such as that above, with regard to some of the more frequently occurring cancers and the impact of nutritional intervention after diagnosis.

Diet may well affect the risk of recurrence. Japanese women, have a low incidence of breast cancer (when compared to women in the West) and this is linked to diet (low overall fat, high fish oils, high trace mineral intake from seaweeds, soya isoflavone intake). But they also have a much better chance of their breast cancer not returning. This may be because they are carrying on doing what they have been doing all along – eating a diet which is protective against the disease. (Normura et al. 1991).

Here is some of the, scant, evidence for nutritional intervention making a difference to patient outcome:

• A study of 448 patients with previous colonic neoplasia (cancer, adenomas and dysplasia) had a 59 per cent lower recurrence in the group of patients who regularly used vitamin supplements an specific benefit was observed for vitamin e, calcium and multivitamins. (Whelan et al. 1999).

• A study, at the University of Arizona, of selenium supplementation and 1300 people with skin cancers (not melanomas) found that after four years those who took the supplement had half the risk of dying when compared to those who took a placebo (it just happened to be of other cancers! – prostate, colon,lung, etc). (Clarke et al. 1996).

• A small study of 11 patients with pancreatic cancer who took large doses of pancreatic enzymes, alongside a whole food diet, had over 80 per cent of patientssurviving one year and 45 per cent surviving two years, far in excess of the average 25 per cent at one year and 10 per cent at two years (Gonzalez et al. 2000).

• High levels of CoEnzyme Q10 were given to 32 ‘high-risk’ breast cancer patients, alongside other antioxidant nutrients and fatty acids. The intervention was adjunctive to prescribed hospital treatment which included chemotherapy. All the patients survived the two years of the study (actuarial data suggests that four of the patients would have died) and six had documented remissions of the breast cancer. Morphine doses were reduced and there was no significant weight loss normally associated with late-stage
cancer. One women had a complete remission. The author of the paper stated that having treated 200 cases of breast cancer per year for 35 years, he ‘had never seen a spontaneous complete regression of a 1.5-2.0 cm breast tumour and had never seen a comparable regression on ay conventional anti-tumour therapy’. A follow up study two years later showed similar results (
Lockwood 1994 and 1995).

• Research from St Thomas’ Hospital concluded "Breast carcinoma patients wishing to change their lifestyle are likely to benefit from a higher dietary fibre/fat ratio combined with regular physical exercise". (Stoll. 1996)

• I have been told by Professor Steven Heys at Aberdeen Royal Infirmary who is conducting research into the effects of essential fatty acids and prostate cancer, I quote "It is clear from laboratory studies that fish oils can prevent the development of many different types of cancer and also reduce the rate of tumour growth if a cancer does occur. Our team has found that fish oils can increase the expression of one of the key genes, p53, which is believed to be important in preventing cancer from developing. In addition, fish oils may also be of benefit in patients with pancreatic cancer, fish oil may help to reduce weight loss and also fish oil supplementation may help patients with other types of cancers to survive for longer periods of time".
His research is to be published shortly.

Nutrition and research

One of the problems is that nutrition does not lend itself well to the gold standard of research – the randomised controlled trial (RCT). This is because, by its nature nutrition is complex. You can only study the effects of, say, the antioxidants vitamins C, or E, up to a point. They will only have limited effects in isolation. You can get much better clues by studying their compound effects – together and alongside other antioxidant nutrients.
This is why it is much more clear that a diet high in fruits and vegetables is of benefit than the benefits of popping individual supplements. Trials examining individual nutrients give mixed results because they are a flawed way of looking at the subject. But this is unlikely to diminish the value of using supplements in a way that takes account of their synergistic action. Researchers at the International Agency for Research on Cancer (in Lyon, France) put it succinctly when they said "Understanding the multi-dimensional nature of diet and of its relationship with different cancers is a major scientific challenge" (Riboli et al. 1996). (They were talking about foods, but the same probably goes for research on supplemented nutrients). Stoll, from St Thomas’ Hosptial also comments "It is suggested that studies focussing on a single nutrient often fail to recognise interactions with
other nutrients" (Stoll 1998). The point I am making is that the mode of research needs to change to suit the discipline and you cannot research nutrients the way that you research drugs. We need intervention trials in hospitals to draw useful conclusions.

This begs an important question – Do you need to take supplements at all when aiming to deal with cancer? There is less controversy about altering diet than about taking supplements. Well if you have already got cancer, you may need a more ‘turbo charged’ helping hand. One nutritional perspective is:
The hospital cancer treatment is designed to deal with the immediate crisis, changes in diet are designed to alter the conditions that might have contributed to the cancer being promoted in the first place, but supplements are needed to give a harder hitting edge to the dietary changes and to make up for some of the negative impact of the hospital treatment.

The use of antioxidant supplementation alongside hospital treatments

Some concern has been expressed about the use of supplements in conjunction with chemotherapy treatments in case the nutrients interfere with the therapy.

The use of antioxidants alongside cancer treatments receives one of three responses from doctors when questioned about their use by patients:

• They might do some good, so go ahead if you want to.
• They can’t do much good, therefore they can’t do much harm – therefore go ahead and use them
• They might interfere with the mechanisms of action of the treatments, therefore better to not use them.

A recent review of the use of antioxidants alongside chemotherapy and radiotherapy concluded: ‘The vast majority of both in vivo and in vitro studies have shown enhanced effectiveness of standard cancer therapies or a neutral effect on drug action’. About one hundred papers examining interactions between antioxidants and hospital treatment were reviewed and of these only three were found to decrease effectiveness of radiation or chemotherapy. What was useful about this study was that it itemised the
compounds (ie vitamin A, C, E) and mentioned whether the studies were human, animal or in vitro, and also classified the information by the type of intervention used – such as different forms of chemotherapies (alkylating agents, antibiotic-type agents, antimetabolites, platinum compounds, plant alkaloids), radiotherapy or hormone therapy (Lamson et al 2000).

Another interesting overview was discussed by Dr Jeffrey Bland on Functional Medicine Update in August 2000 on the work of Dr Daniel Labriola, regarding the use of antioxidants alongside chemotherapy discussing the concerns of oncologists and the use of antioxidants, which might interfere with their action (Labriola et al 1999). To summarise his comments:
• The mechanisms of chemotherapeutics for different tumours have different effects.
• Only certain chemotherapeutic agents mechanistically use the increased production of ROS (reactive oxygen species) as their cytotoxic /apoptopic stimulating effects – for those agents it might be questionable to use antioxidants simultaneously (though see the point below).
• It is suggested that if antioxidants are used that they be taken outside the clinical window when the medication is working by way of increasing oxidant reactions in cells and enhancing apoptotic cell death. In most cases turnover of the chemotherapeutic agent are fairly quick – between 12-24 hours – and a programme of using antioxidants by ‘pulsing’ them (ie using them at different times to the drugs) is likely to be most useful.
• Specific antioxidants quench only certain types of ROS, so not just any one quenches all types of radicals and ROS equally efficiently. Antioxidants such as glutathione, vitamin E, lipoic acid, CoQ10, flavanoids and vitamin C all have differing effects. More precision and understanding will lead to better therapeutics.

SUMMARY

It seems that there is a very real demand for nutritional information from a significant number of cancer patients. This is evidenced by:

• Studies which indicate that cancer patients are using supplements.
• The sheer volume of book sales on the subject.
• The wide range of information on the internet (some of it better than others).
• The demand experienced by privately practicing nutrition consultants and the difficulty the few charities and support groups who offer this type of information have in keeping up with the demand.
• On a personal note I find that that any workshops I conduct on the subject are always well attended and booked up months in advance.

There are many considerations to take into account when looking at the possibility of nutritional therapy being used as a standard part of cancer treatment. It seems to me that one of these considerations are reasons for not doing providing nutritional help:

• There are obviously financial and budgetary considerations. However, it is my opinion, and I would hazard a guess that this view is held by many nutritional therapists, that in the long run nutritional therapy can save money for medical treatment due to improved overall health (Bendich et al 1997).
• It is the opinion of many people who practice nutritional therapy that there is early evidence that using the discipline alongside hospital treatments will lead to enhancement of efficacy of oncology treatments ( Lamson et al 2000 andZiegler et al 1992). There is only one way to find out for sure and that is to run trials.
• Training of nutritional therapists in the specifics of working within the cancer field would obviously be required, with protocols agreed with the hospitals. Training of doctors and nurses in the basics of nutrition would also be desirable and, again, is in line with the recommendations of the aforementioned Select Committee report.
• Ethical considerations are always an issue, however in the light of the fact that people are using nutrition anyway, it could be argued that it would be unethical to not offer nutrition information and support and to run trials to determine efficacy. Patients would inevitably self-select, and nutrition will not be for everybody. But if it is on offer, I suspect that the nutritionists working alongside the oncology departments would be knocked down in the rush!