Supplements: What are the Guidelines for Cancer Patients?

Shayne RobinsonBy Shayne Robinson, RD, CSO, CDN

As an oncology dietitian, I encourage my patients to eat a balanced diet of whole unprocessed foods. To quote the author Michael Pollan, “Eat food, not too much, mostly plants.” So where do supplements fit in the treatment of a cancer patient?

The latest National Comprehensive Cancer Network (NCCN) Guidelines on Cancer Survivorship does not recommended supplements for most survivors except, when there are nutritional deficiencies, or concurrent conditions like osteoporosis or cirrhosis. Furthermore, there is little data to support using vitamins or other dietary supplements to either prevent cancer, control cancer, or prevent the reoccurrence of cancer after treatment. Taking vitamin supplements does not replace the need to maintain a healthy diet. It is better to get these nutrients straight from the source, and all efforts should be made to obtain nutrients naturally. Survivors of certain cancers are at risk for vitamin deficiencies based on their cancer treatment, and supplements should be recommended by a healthcare professional on a case-by-case basis.

The American Cancer Society (ACS) and The American Institute of Cancer Research (AICR) also review nutrition research to develop guidelines for cancer prevention and cancer survivors. The ACS guidelines on nutrition and physical activity for cancer prevention clearly state, “Can dietary supplements lower cancer risk? Present knowledge indicates no. While a diet rich in vegetables, fruits, and other plant-based foods may reduce the risk of cancer, there is little evidence that dietary supplements can reduce cancer risk.” The AICR’s guideline on supplements states, “Don’t use supplements to protect against cancer. To reduce your risk of cancer, choose a balanced diet with a variety of foods rather than taking supplements.” These guidelines do acknowledge that there are special individual situations where supplements would be appropriate, but these do not include cancer prevention, treatment, or survivorship.

So remember moderation is key, and a diet rich in fruits, vegetables, and other plant based sources is best.

Shayne Robinson RD CSO CDN is an oncology dietitian at NewYork Presbyterian Weill Cornell’s Ambulatory Care Network’s Outpatient Practice. To see a dietitian at the outpatient nutrition practice, call (212) 746-0838 (physician referral required).

How Important is Minimal Residual Disease Negativity in Measuring the Successful Treatment of Chronic Lymphocytic Leukemia

Dr. Richard Furman, M.D.
Dr. Richard Furman, M.D.

Recently the Oncology Times asked Dr. Richard Furman his opinion on whether a complete response (CR) and minimal residual disease (MRD) negativity are still requisites for the successful treatment of CLL patients. MRD refers to the small number of leukemic cells that remain in a patient after treatment and can only be detectable using sensitive techniques. In patients who achieve complete responses, MRD can remain and cause relapse. Dr. Furman believes that while MRD negativity is always preferred, it is not the most important measure of outcomes. He stated,

“The most important part of the debate surrounds survival. From a patient’s perspective,  overall survival is the single most important goal,” Furman said. “If achieving MRD negativity comes at a cost of toxicities, short term or long term, it may not translate into improved survival.”   

The combination of fludarabine, cyclophosphamide, and rituximab (FCR) generates deeper remissions and more MRD negativity than fludarabine and rituximab (FR), but can have an impact upon long term marrow health, leading to 8 percent of patients developing secondary myeloid neoplasias (MDS and AML). We may have 60 percent long-term survival with FCR in mutated CLL patients, but if we are losing 8 percent of patients to bone marrow failure, that has to be considered. Still the long-term effects of FCR chemotherapy are unknown. 

Fortunately, CLL patients have another option with BCR and Bcl2 antagonists that may markedly improve survival. The ideal circumstance for a CLL patient would be to obtain MRD negativity without having any additional toxicities. This is where the novel treatments, including BCR antagonists, BCL2 antagonists, and CAR T cells will hopefully take us. With BCR antagonists, the depth or remission continues to improve with continued therapy. While almost all of the initial responses were partial responses with very few complete responses, over time the number of complete responses has increased. This will hopefully translate into MRD negative responses one day. This is the importance of progression free survival, as these patients who have not progressed, and remain on therapy, have the potential to continue to improve their response.

Improved survival of CLL patients over the past few decades shows an apparent change in the natural history of the disease. But Furman claims the advance in overall survival is related to lead-time bias. “We are diagnosing patients earlier in Binet stage A. There has been an increase in overall survival for patients as a group. By stage, there is no benefit for Binet stage A and B. A benefit is seen for Binet stage C. This may be due to better supportive therapies and novel agents, or to a shift to earlier stage disease at diagnosis,” he said, noting there is a great need for prognostic markers.

The full debate and rest of Dr. Furman’s response can be read on the Oncology Times website.

Treating Mantle Cell Lymphoma: Why Are Patients Benefitting From New Therapies?

Picture1By Peter Martin, MD

Most clinicians and researcher agree since mantle cell lymphoma (MCL) was first described 25 years ago patient outcomes have improved considerably. What remains unknown, however, is why outcomes are improving.

In an international, phase III clinical trial from the European MCL Network that was recently published in The Lancet, investigators demonstrated that progression-free survival could be doubled by the addition of rituximab, dexamethasone, cytarabine, cisplatin (R-DHAP) to standard chemotherapy and autologous stem cell transplantation. Whereas in the early 1990s, data suggested that patients might expect to live for 2-4 years, new findings demonstrated that patients can achieve decade long remissions. The strange thing about this remarkably positive study is that the overall survival was similar in both arms despite significant differences in virtually all other outcome measures. In fact, in the vast majority of MCL related phase III trials, despite great improvements in depth and duration of response, the overall survival of the experimental and control arms is the same.

While we celebrate the successes that each of these studies represents, important questions remain. Why are the patients in the control arms doing so well? Why are patients treated with the older, less effective therapies living as long as patients randomized to receive new therapies, and why are they living longer than patients receiving those therapies a couple decades ago?

Some of these questions can be answered by perception biases and advances in supportive care. For example, if patients in 2016 are being diagnosed with MCL earlier than they might have been diagnosed in the 1990s, they would appear to live longer, a phenomenon known as lead-time bias. Improvements in pathology may also lead to what is known as selection bias. Previously, patients with less aggressive variants of MCL were misdiagnosed as having other kinds of lymphoma, while a more representative sample is included in today’s studies. Similarly, perhaps people enrolled in recent clinical trials are healthier than they were in the past, another form of selection bias. Perhaps supportive care has improved, allowing people to live longer with lymphoma, or tolerate therapies that might have been considered overly aggressive in the past. If any or all of these hypotheses are true, hematologists around the world cannot claim credit for the perceived improvements.

It is clear that people with MCL are living longer with a higher quality of life. They have more options for treatment and these gains are due to clinical trials. In the past decade, the use of rituximab has expanded while bortezomib, temsirolimus, ibrutinib, and lenalidomide, all better tolerated than many historical options, have been approved. If this is true, it suggests that the path to continued improvements relies on the development of new, well-tolerated approaches, and it suggest that front-line therapies without curative potential must evolve to become less toxic so that subsequent lines of therapy remain feasible.