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Another Big Picture Question: For Cancer Patients, What is the Most Important yet Under Appreciated Supplement?

10/01/2018 - Product Newsletter #318

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ANOTHER BIG PICTURE QUESTION: FOR CANCER PATIENTS, WHAT IS THE MOST IMPORTANT YET UNDER APPRECIATED SUPPLEMENT?

INTRODUCTION

In January of this year I started a discussion that continued into a whole series of newsletters about what I felt was the most important yet under-appreciated nutritional supplement.  Based on the tremendous discrepancy between reported use (very low) of different nutritional supplements, as shown in various published surveys, and the massive amount of research that emphasized the importance of optimal intake for virtually every chronic ailment, I came to the conclusion that this supplemental nutrient was protein.  Of course, this conclusion was based on research on the general American population.  Could the same be stated for some of the sickest people in the US, cancer patients?  What follows is a review of several published papers that leads me to overwhelmingly conclude that the answer is an emphatic yes.

WHAT IS THE RATE OF USE OF PROTEIN SUPPLEMENTS AMONG CANCER PATIENTS?

The first aspect of the title of this newsletter I would like to address is "under-appreciated."  The idea that protein supplementation was the most under-appreciated nutritional supplement used by cancer patients was addressed in the recently published paper "Use of dietary supplements at a comprehensive cancer center" by Luo and Asher (Luo Q & Asher G.  J Alt Comp Med, Vol. 24, Nos. 9 & 10, pp. 981-987, 2018).  The first quote I would like to feature from this paper points out, as you might expect, cancer patients tend to use dietary supplements more frequently than the general US population:

"Dietary supplement use among cancer patients is more prevalent than that in the general U.S. population and ranges from 50% to 85%, depending on factors such as cancer type and survey methods (e.g., time recalls, sampling framework, dietary supplements surveyed)."

Unfortunately, despite increased supplement use by cancer patients, it is often difficult for them to obtain reliable information on optimal supplement use.  Therefore, they tend to attempt to gain this information from several, often questionable resources:

"...cancer care providers often have little training about the supplements themselves, and patients often seek or receive information on dietary supplements from both professional sources (e.g., primary and cancer care providers) and nonprofessional sources (e.g., mass media, family, friends).  The role of information sources on patients' dietary supplement use during or after cancer treatment is not well understood."

A survey on dietary supplement use by cancer patients

With the above introductory information in mind, the authors of the paper, Luo and Asher, conducted a study of cancer patients in North Carolina:

"A cross-sectional survey of adult cancer patients seeking care at the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center (LCCC) between 2010 and 2012 was conducted."

Those eligible for the study were the following:

"...eligible participants were English-speaking, 21 years or older, diagnosed with breast, colorectal, lung, or prostate cancer, and treated at the UNC LCCC."

Data was collected by sending an introductory letter, questionnaire, and return postage envelope to 1794 patients.  The demographics of those who responded are the following:

"Six hundred and three (33.6%) participants completed the questionnaires.  Ninety-eight percent of the respondents were non-Latino, 79% were white, and 62% were female.  Compared with nonrespondents, respondents were more likely to be female, white, at early cancer stage, and have breast cancer, but less likely to have lung or colorectal cancer."

What were the findings of the study?  The authors report:

"Before cancer treatment, 399 (66%) of all 603 respondents reported using vitamin supplements, 198 (33%) reported using mineral supplements, 101 (17%) reported using herbal supplements, and 163 (27%) reported using other supplements.  Four hundred and twenty-eight (71%) reported using at least one dietary supplement before cancer treatment.  Two hundred and thirteen (35%) respondents received chemotherapy, and 128 (60%) respondents who received chemotherapy reported using at least one dietary supplement during treatment.  Two hundred and seventy (45%) respondents underwent radiation treatment, and 166 (61%) respondents who received radiation reported using at least one dietary supplement during radiation.  Three hundred and twenty-five (54%) participants reported using vitamin supplements during cancer treatment, where the most common vitamin supplements were multivitamins (313, 52%) vitamin D (88, 15%) vitamin B12 (39, 6%), vitamin C (34, 6%), and folic acid (18, 3%).  A total of 171 (28%) reported using mineral supplements during cancer treatment, where the most common mineral supplement was calcium (208, 34%).  Although vitamin and mineral supplement use was most commonly reported (56% during initial treatment), the non-vitamin, non-mineral supplement use (e.g., herbals, omega-3 fatty acids, probiotic, glucosamine) was also commonly reported (25% during treatment).  Among participants reporting dietary supplement use during treatment (n = 354), 64 (18%) specifically reported using an herbal supplement during cancer treatment."

It is also interesting to note that 76% (325/427) of the respondents who were using supplements before cancer treatment continued supplement use during treatment.

Who provided nutritional information to the patients?  The reported results concerning this question was similar to what was reported in the introductory statements from this paper noted above:

"When seeking advice on dietary supplement use, respondents most often cited professional sources (75%), such as their primary care provider or oncologist.  However, media (44%) and lay sources (47%), such as friends, family, or support groups, were also commonly mentioned.  Among professional sources, primary care providers (51%) were more frequently consulted than oncologists (35%), while complementary and alternative medicine (CAM) providers (10%), pharmacists (8%), other conventional providers (3%), and nutritionists (2%) were uncommonly consulted."

What were the results concerning the subject of this newsletter, the use of protein supplements by cancer patients? 

Less than 5 patients (not 5%) reported using protein supplements!!

What is the significance of this?  More on that later.

Authors' thoughts about the reported data

Before presenting the actual quotes - a few comments on what you are about to read.  As you will see, while the authors do suggest that vitamin and mineral supplementation can provide benefits to cancer patients, the overall impression left by the authors is that vitamin and mineral supplements are somewhat of a nuisance to optimal cancer therapy, more often than not leading to no benefit or adverse outcomes.  What about herbal supplements?  Luo and Asher do not mention any benefits.  Instead they suggest the only possible impact is increased risk to health.

First, concerning vitamin and mineral supplementation, the authors state:

"During initial cancer treatment, more than half of patients reported use of vitamin and mineral supplements.  This common vitamin and mineral supplement use needs to be noted because certain vitamin and mineral intake may interact with cancer therapy or carry potential benefits or harm for cancer survivorship.  For example, a randomized trial of antioxidant vitamins to prevent second primary cancers in patients with head and neck cancer, conducted in France, found that α-tocopherol supplementation produced adverse effects on the occurrence of second primary cancer and on cancer-free survival.  A review of vitamin and mineral supplement use in relation to cancer progression or mortality reported that vitamin D at higher than standard doses may improve cancer-specific and overall survival for several cancer types and that excessive folic acid in patients with established cancer may be harmful."

In contrast to the somewhat balanced viewpoint stated in the above quote on the use of vitamin and mineral supplementation with cancer patients, Luo and Asher summarily categorize all herbal supplementation with cancer patients as a potential risk to health:

"Herbal supplements, however, are likely to carry greater risk of pharmacokinetic (PK) interaction with chemotherapy agents compared with vitamin, mineral, and other supplements, which less commonly cause PK interactions."

In addition:

"Among dietary supplement users during active cancer treatment, 18% used an herbal supplement, which are likely to carry greater risk of interaction with chemotherapy agents compared with vitamin, mineral, and other supplements."

Some final thoughts on this paper

First, Luo and Asher seem to suggest that professional sources of advice on dietary supplements will give more reliable information than a "nonprofessional source":

"Although many respondents sought dietary supplement advice from professional sources, the use of nonprofessional sources remains high."

Interestingly, the authors point out that the vast majority of these "professional sources" were primary care providers and oncologists.  While I would agree that these practitioners are "professional," I have my reservations about considering them reliable "sources" of information on dietary supplements.  Compounding the problem is that only 12% of the respondents consulted what might be regarded as legitimately reliable resources for sound advice on dietary supplements - complementary and alternative medicine (CAM) practitioners and nutritionists.

With the above in mind, the concerns expressed by Luo and Asher about the use of dietary supplements by cancer patients are, for me, less an issue of dietary supplements per se but an issue of the fact that, for the majority of the patients, practitioners and individuals with minimal to no training and clinical experience with dietary supplements were making the recommendations.

WHAT DO KNOWLEDGEABLE PRACTITIONERS RECOMMEND FOR OPTIMAL NUTRITIONAL SUPPORT FOR CANCER PATIENTS?

In "Nutrition and aging: a practicing oncologist's perspective" by Jain and Dotan (Jain R & Dotan E.  Curr Oncol Rep. Vol. 19, No. 71, 2017), in contrast to Luo and Asher who seem to feel that supplements present more potential risk than potential benefit despite the fact that, in their study, recommendations in the majority of instances were made by questionable resources, the authors feel that competent nutritionists can make a valuable contribution to care of the cancer patient when acting as part of highly qualified cancer care team:

"Regardless of the disease site or time point in the course of the malignancy, multidisciplinary collaboration between the oncologist and other members of the treatment team - including nurses, dietitian, social workers, physical therapists, primary care providers/geriatricians, and palliative care physicians - is critical.  By strategically addressing the complex nutritional concerns in older patients with cancer, we continue to strive toward improved patient outcomes and achieving the highest degree of patient and caregiver satisfaction."

Why do knowledgeable cancer care practitioners support the idea of "strategic" attention to the nutritional needs of cancer patients?  First, the reality of cancer is that it is largely a disease of older individuals.  Jain and Dotan point out:

"Cancer is largely a disease of aging, with a median age of 65 at diagnosis and a median age of 72 at death.  With over half of all new cancer diagnoses in individuals age 65 and older, we must have a comprehensive understanding of the unique characteristics of this heterogeneous patient population."

What is one of the most unique characteristics of this patient population?  As noted by the authors, significantly suboptimal nutrition:

"An analysis of older patients with cancer showed that 71% had lost more than 10% of their weight with 44% having a body mass index (BMI) <20.  Undernutrition is highly prevalent in the outpatient setting, with 42.5% of older oncology outpatients having ≥10% weight loss.  The consequences of undernutrition and associated sarcopenia are profound.  Complications associated with these problems are higher rates of treatment-related toxicity, increased risk of hospitalization, depletion of muscle strength and performance status, increased symptom distress, and an overall reduction in quality of life (QOL).  Furthermore, undernutrition in older patients is associated with early mortality.  Early identification and aggressive intervention for undernutrition is critical, especially in high-risk older cancer patients."

With the above in mind, according to Jain and Dotan, what should be the focus of optimal nutritional support for the cancer patient?  Interestingly, it was none of the herbs or nutrients recommended by the practitioners of questionable nutritional expertise in the Luo and Asher study.  In fact, Jain and Dotan feel the main focus should be on macronutrients, most notably protein:

"Manipulation of macronutrient (namely, protein) consumption is the basis of most nutritional interventions with the goal of achieving anabolic metabolism, preserving muscle mass, and ultimately reversing weight loss.  Specific components of protein, such as the branched chained amino acid leucine, are particularly important with properties that enhance muscle synthesis and improve anabolic efficacy."

Furthermore:

"Recommendations for protein intake in older patients are largely extrapolated from data in healthy older individuals and most suggest consumption of 0.8 to 1.5 g/kg spread equally throughout the day.  Aggressive nutritional support to help reach this protein goal is critical in older cancer patients as both advanced age and cancer are independently associated with sarcopenia."

Why did Jain and Dotan make preservation of muscle mass such a core issue?

As you may have noticed, the main reason for focusing on protein above all other nutrients was maintenance of muscle mass.  Why was maintenance of muscle mass such a high priority for Jain and Dotan?  To answer this question I would like to highlight two recently published papers.  The first is "Preservation of muscle mass as a strategy to reduce the toxic effects of cancer chemotherapy on body composition" by Pin et al (Pin F et al. Curr Opin Support Palliat Care, published online ahead of print 2018).  This paper makes it clear that the muscle losses which take such a toll on both mortality and quality of life in cancer patients are directly linked with chemotherapy:

"It is now clear that chemotherapy plays a direct role in the loss of muscle mass and muscle strength in cancer patients (often referred to as 'cachexia'), a condition that can persist for months to years following remission.  Notably, patients suffering from cachexia-related symptoms are often unable to complete treatment regimens and may require delays in treatment, dose limitation, or discontinuation of therapy."

How direct is the role?  The authors conclude:

"Changes in body composition, mainly resulting in depletion of skeletal muscle mass, have been linked to the use of anticancer drugs.  On the basis of a growing number of experimental and clinical studies, there is now substantial agreement on the idea that the loss of lean mass represents an accurate prognostic factor for augmented treatment toxicity, worsened outcomes, and overall reduced survival in cancer patients."

What is one of the best ways of increasing muscle mass in cancer patients?

As you might guess from where I began with this newsletter, research suggests that increased protein intake can be of tremendous benefit in reducing one of the main causes of increased mortality and loss of quality of life in cancer patients undergoing chemotherapy: loss of muscle mass.  This suggestion was supported by the other recently published paper I alluded to above, "Muscle protein anabolism in advanced cancer patients: response to protein and amino acids support, and to physical activity" by Antoun and Raynard (Antoun S & Raynard B.  Annals of Oncology, Vol. 29, Supplement 2, pp. ii10-ii17, 2018).  The authors first state:

"Early in the tumor evolution with low or normal protein intake, there was a decrease in muscle protein anabolism (two of the three studies with muscle biopsies."

Next:

"With increasing protein intake, whether it contains leucine or not, five of six studies showed the possibility of increasing the net balance protein.  It was observed for the three studies that explored the whole protein turn over, and for two of three that explored the fractional synthetic rate by muscle biopsies."

SOME FINAL THOUGHTS

As you all know, much information has been generated over the years about the role of diet and nutritional supplements in aiding the plight of cancer patients, some positive and most negative.  Why all the controversy?  Many of our critics would suggest that this controversy of the role of clinical nutrition in cancer care is solely caused by the fact that, in reality, dietary changes and nutritional supplements have no rightful place in cancer care and can, at best, not create problems and, more often than not, interfere with optimal cancer treatment.  However, based on the research I have presented above, I would suggest that the controversy, in fact, has been created by the many poorly informed practitioners who are making incorrect and/or detrimental dietary and supplemental recommendations.  As I hope you can see, the knowledgeable nutritional practitioner, when acting as part of a quality, highly trained cancer care team, can make a tremendous difference in improving treatment efficacy plus length and quality of life by doing something as simple as optimizing muscle mass and function through optimization of protein intake.

We would like to remind you that we have several excellent protein-rich dietary supplements from Moss Nutrition:

SarcoSelect & SarcoSelect DF

Select Meal & Select Meal DF in 2 flavors

Select Whey in 3 flavors

Organic Select Pea Protein in 2 flavors

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