Many cancer patients undergoing palliative care take dietary supplements such as vitamins when there is a lack of further treatment options available, to enhance the quality of life, or they take along with their ongoing treatments to cope with the side effects of the current or previous treatments. However, every cancer is unique. Dietary supplements such as multi-vitamins, omega-3 fatty acids (from marine sources), etc may not benefit all cancers and may even adversely interact with specific therapies, if not chosen scientifically. There is a need to explore personalized nutrition which scientifically matches the cancer characteristics, ongoing treatments and lifestyle of the cancer patients under palliative care.
Cancer is the second most leading cause of mortality worldwide. A diagnosis of cancer affects not only the patient, but also his or her family. With the recent advancements in medical treatments and earlier detection, the death rates of many cancer types such as breast cancer, and the number of new cases in cancer types such as lung cancer have reduced in the last few years (American Cancer Society, 2020). There are different types of cancer therapy regimens available today including different classes of chemotherapy, immunotherapy, targeted therapy, hormonal therapy and radiation therapy. The oncologist takes a decision on which therapy regimen to be used for a cancer patient based on various factors including type and stage of the cancer, location of the cancer, existing medical conditions of the patient, patient’s age and general health.
However, despite the medical advancements and improvement in the number of cancer survivors over the last few decades, cancer as well as cancer therapy regimens can lead to side-effects including different physical symptoms such as pain, fatigue, mouth ulcers, loss of appetite, nausea, vomiting, shortness of breath, and insomnia. The cancer patients may additionally have psychological, social and emotional problems. Depending on the type and extent of the therapy regimen, it can cause mild to severe adverse side-effects. These side-effects significantly impact the quality of life of the cancer patient. Palliative care aims at providing relief to cancer patients from these health-related sufferings and aids in improving their quality of life.
What is Palliative Care?
Palliative care, also known as Supportive care, is the care provided to the cancer patients focused on improving their quality of life and physical symptoms. Palliative care was initially considered as hospice care or end-of-life care when curative treatment was no longer an option of treatment for patients with life threatening diseases such as cancer, but over time, this has changed. Today, palliative care is introduced to a cancer patient at any point of his or her cancer journey- right from cancer diagnosis to the end of life.
- Palliative care may be integrated along with cancer treatment regimens such as chemotherapy and radiation therapy to help to slow, stop or cure the cancer.
- Palliative care may provide solutions that can only improve the quality of life of the patient who is diagnosed with cancer and has initiated a cancer treatment.
- Palliative care may be provided to a patient who has completed the cancer treatment but still have side-effects or physical symptoms.
Nutrition for Patients in Palliative Care
Cancer treatment such as chemotherapy is used to kill the fastly dividing cancer cells. However, during this process, different parts of our body where the normal healthy cells divide frequently are affected leading to collateral damage. In many such cases, it becomes difficult for the patient to continue taking the physician prescribed treatment or conventional treatment. Taking scientifically right foods and dietary supplements is one of the options for such palliative care situations.
For many years, the key goal of nutrition in palliative care and hospice care has been only to improve the quality of life of cancer patients. However, now that palliative care treatment is integrated at various stages of the cancer journey, the nutrition (including foods and dietary supplements) for the cancer patients should be designed to benefit one or more of the different aspects of cancer survivorship which impacts quality of life, general health and helps in controlling cancer recurrence and disease progression by lowering the cellular factors which are promoting the disease.
Evidence on Benefits of Dietary Supplement Intake/Infusions in Palliative Care
Let us now have a look at some of the studies published on the impact or benefit of taking specific dietary supplements or foods or supplement infusions by palliative cancer patients on their physical symptoms or quality of life.
Supplementation of Vitamin D in Solid Cancer Patients under Palliative Care
Normal levels of vitamin D are essential for maintaining the structure and function of bones and muscles, as well as the functional integrity of different physiological systems of our body. Food sources rich in Vitamin D include fatty fishes such as salmon, tuna and mackerel, meat, eggs, dairy products and mushrooms. The human body also makes Vitamin D when the skin is directly exposed to sunlight.
In a cross-sectional study published in 2015, the researchers of Spain evaluated the association of Vitamin D deficiency with health-related quality-of-life issues, fatigue, and physical functioning in locally advanced or metastatic or inoperable solid cancer patients under palliative care. (Montserrat Martínez-Alonso et al, Palliat Med., 2016) Among the 30 patients with advanced solid cancer under palliative care, 90% were vitamin D deficient. The analysis of the results of this study found that an increase in vitamin D concentration decreased the incidence of fatigue and improved physical and functional well-being.
In another study published in 2017, the researchers from the Karolinska Institutet, Stockholm, Sweden investigated whether the supplementation of vitamin D could improve pain management, quality of life (QoL) and decrease infections in the cancer patients under palliative care(Maria Helde-Frankling et al, PLoS One., 2017). The study included a total of 39 cancer patients under palliative care who had low Vitamin D levels (with levels of 25-hydroxyvitamin D < 75 nmol/L). These patients were supplemented with vitamin D 4000 IE/day, and were compared to 39 untreated control patients. The impact of Vitamin D supplementation on Opioid doses (used for managing pain), antibiotic consumption and quality of life were monitored. The researchers observed that after 1 month, the group supplemented with vitamin D had a significantly decreased opioid dose compared to the untreated group with a difference between the doses used in the 2 groups almost doubled after 3 months. The study also found that the quality of life improved in the Vitamin D group the first month and that this group had significantly lower consumption of antibiotics after 3 months compared to the untreated group.
The studies indicate that intake of dietary Vitamin D supplements in advanced solid cancer patients under palliative care may be safe and may benefit the patient by improving pain management and decreasing infections.
Supplementation of Omega-3 fatty acid in Advanced Esophago-Gastric Cancer patients treated with Palliative Platinum based Chemotherapy
Omega-3 Fatty Acids are a class of essential fatty acids which are not produced by the body and are obtained from our daily diet. The different types of omega-3 fatty acids are eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and alpha-linolenic acid (ALA).
Sources of Omega 3 fatty acids : Fish and fish oils are the best sources of Omega-3 fatty acids such as EPA and DHA. However, plant sources such as walnuts, vegetable oils and seeds like Chia seeds and flax seeds are the common sources of Omega-3 fatty acid like ALA.
The researchers from the University of Leicester,U.K. recently published a clinical study which analyzed the outcomes of palliative chemotherapy – EOX along with a weekly infusion of Omega-3 fatty acid sources (Omegaven®) in 20 patients with advanced esophago-gastric adenocarcinoma. (Amar M Eltweri et al, Anticancer Res., 2019) The results were compared with 37 control patients who had received EOX chemotherapy alone. The study found that supplementation of Omega-3 fatty acid improved the radiological responses, with partial response improved from 39% (EOX alone) to 73% (EOX plus omega-3). The researchers also found that grade 3 or 4 toxicities such as gastrointestinal toxicity and thrombo-embolism were also reduced in those who received omega-3 along with EOX.
Including food sources and dietary supplements of omega-3 fatty acids in the right amounts as part of a healthy diet of the cancer patient undergoing palliative EOX chemotherapy may be beneficial.
Palliative Vitamin C Supplementation in Patients With Radiotherapy-Resistant Bone Metastases
Vitamin C, or ascorbic acid, is a strong antioxidant and one of the most commonly used natural immunity boosters. The top sources of Vitamin C include citrus fruits such as oranges, lemons, spinach, red cabbage, grapefruits, pomelos, and limes, guava, bell peppers, strawberries, kiwi fruit, papaya, pineapple, tomato, potatoes, broccoli and cantaloupes.
In a study published in 2015, the researchers from Bezmialem Vakif University, Istanbul, Turkey investigated the effects of supplementation of Vitamin C (ascorbic acid) on pain, performance status, and survival time in cancer patients. (Ayse Günes-Bayi et al, Nutr Cancer., 2015) The study included 39 patients with radiotherapy-resistant bone metastases. Out of these, 15 patients received chemotherapy, 15 patients received an infusion of Vitamin C/ascorbic acid and 9 control patients were treated with neither chemotherapy nor vitamin C. The study found that the performance status had increased in 4 patients of vitamin C group and 1 patient of chemotherapy group, however, the performance status in control group had decreased. The study also found 50% reduction in pain in the vitamin C group along with an increase in the median survival time by 8 months. ( Ayse Günes-Bayir et al, Nutr Cancer., 2015)
In short, dietary Vitamin C supplements or infusions at right amounts may benefit cancer patients with radiotherapy-resistant bone metastases by reducing pain and increasing their performance status and survival rate as compared to other patients who did not receive Vitamin C.
Supplementation of Curcumin for long-term stabilisation of Myeloma
Sometimes, the adverse effects of cancer treatments can make it very difficult for the patient to continue with the treatment. Or a stage comes when there is a lack of any more treatment options available for the patients. In such cases, personalized nutrition including scientifically right foods and dietary supplements which match the cancer characteristics might benefit the patient.
Curcumin is the key active ingredient of the curry spice Turmeric. Curcumin is known to have antioxidant, anti-inflammatory, antiseptic, anti-proliferative and analgesic properties.
A case study was published in 2015 about a relapsing myeloma patient, aged 57 years, who had entered into the third relapse and due to the absence of further conventional anti-myeloma treatment options, initiated curcumin intake on a daily basis. The study highlighted that the patient took 8 g of oral curcumin along with bioperine (to improve its absorption ability) and has since remained stable for more than 5 years. (Zaidi A, et al., BMJ Case Rep., 2017)
This study indicates that Curcumin supplementation may help myeloma patients in palliative care in long term stabilization of the disease. However, more defined clinical trials are required to establish the same.
In summary, data from these small clinical trials and case studies suggest that use of right foods and supplements may benefit palliative care patients in pain management, decreasing infections and improving physical symptoms and general health. The hope now is to have much larger clinical trials to establish the same.
A significant number of cancer patients under palliative care take random dietary supplements such as vitamins along with their conventional treatment or when there is a lack of any more treatment options available, to cope with the side effects of the current or previous treatments, manage symptoms and enhance the general well-being. Every cancer is unique and the disease characteristics or disease promoting pathways vary from cancer to cancer. Cancer treatments can also have adverse interactions with dietary supplements if not chosen scientifically. Hence, the use of random supplements may worsen your cancer and negatively impact the cancer treatment. Thus, there is a need to explore personalized nutrition of food and dietary supplements which scientifically matches the cancer characteristics, ongoing treatments and lifestyle of the cancer patient under palliative care thereby benefiting them.
Cancer patients often have to deal with different chemotherapy side effects which affect their quality of life and look out for alternative therapies for cancer.Taking the right nutrition and supplements based on scientific considerations (avoiding guesswork and random selection) is the best natural remedy for cancer and treatment related side-effects.